# 護理長收到八位個案的報告。將每項報告拖曳至下一輪護理巡視最適當的優先分類。 > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=395441&lang=zh-tw > language: zh-TW > subject: Establishing Priorities > category: MOC ## 題目 護理長收到八位個案的報告。將每項報告拖曳至下一輪護理巡視最適當的優先分類。 **1.** 甲狀腺切除術後 30 分鐘：新出現的吸氣性喘鳴與躁動 Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **2.** 產後 6 小時：子宮鬆軟且會陰墊在 15 分鐘內飽和 Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **3.** 盜汗與意識混亂，即時血糖 48 mg/dL Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **4.** 腹部手術後 2 小時：尿液輸出總量 20 mL Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **5.** 靜脈注射鴉片類藥物後 45 分鐘疼痛仍為 8/10；呼吸速率為 16/min Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **6.** 穩定個案要求為明天排程的出院進行衛教 Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **7.** 常規乾式換藥將於 30 分鐘後到期；生命徵象無變化 Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats **8.** 穩定個案要求護理師完成非緊急的工作證明 Select a category Assess and act immediately Schedule after urgent needs Follow up promptly after immediate threats ## 解析 呼吸道受損、未控制的產後出血及有症狀的嚴重低血糖需要立即評估與處置。新發生的少尿及鴉片類藥物無法緩解的疼痛屬於非預期變化，需在處理立即威脅後迅速追蹤。穩定個案的衛教、常規護理及非緊急要求可暫緩。 ## 深入解析 快速解答 將呼吸道、活動性出血及有症狀的低血糖排在非預期但目前穩定的變化之前，再處理排程需求。 為何此為正確 甲狀腺手術後的吸氣性喘鳴可能表示呼吸道阻塞正迅速惡化。子宮鬆軟合併會陰墊飽和提示產後出血。盜汗與意識混亂合併血糖 48 mg/dL 表示神經性低血糖。新發生的少尿及持續劇烈疼痛需要及時再評估，但當報告的生命徵象仍穩定時，其優先順序不應高於活動性呼吸道問題、出血或血糖急症。 NCLEX 決策原則 首先辨識若不立即處置可能惡化或死亡的個案。接著處理非預期變化。最後完成可預期、穩定或排程的需求。 為何較低優先順序的報告需暫緩 出院衛教、常規換藥及工作證明的要求仍然重要，但短暫延後不會造成相同的立即生理風險。參考資料 1NCSBN 2026 NCLEX-RN Test Plan照護管理、優先順序及臨床判斷架構 ## 臨床情境 交班優先順序 護理長必須依立即威脅、非預期變化及穩定度排序床邊評估。目前無額外人員可立即支援。 ## 重要概念 - **空氣傳播防護措施** — 針對能懸浮在空氣中的病原體所採取的防護措施。 - **飛沫傳播防護措施** — 針對透過較大呼吸道飛沫傳播的病原體所採取的防護措施。 - **接觸傳播防護措施** — 針對透過直接或間接接觸傳播的病原體所採取的防護措施。 ## 相同主題題目 - [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=zh-tw) - [At shift change, a charge nurse receives six postoperative reports. Classify the timing of…](https://mymerci.kr/pages/nclex_q.php?qn_id=393410&lang=zh-tw) - [Review the nurse's escalation timeline for a postoperative client whose condition is deter…](https://mymerci.kr/pages/nclex_q.php?qn_id=393500&lang=zh-tw) - [The nurse receives report on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=393675&lang=zh-tw) - [Four hours after open reduction and internal fixation of a fractured tibia, a client repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=394047&lang=zh-tw) - [The nurse receives reports on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=394076&lang=zh-tw) - [During a mass casualty incident, which client should be assigned a delayed priority rather…](https://mymerci.kr/pages/nclex_q.php?qn_id=394136&lang=zh-tw) - [During disaster triage, a client is not breathing after the airway is opened and repositio…](https://mymerci.kr/pages/nclex_q.php?qn_id=394166&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=395441&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=395441&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=395441&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=395441&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=395441&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_