# 四位病人抵達緊急照護診所。護理師應首先評估哪一位病人？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396577&lang=zh-tw  
> language: zh-TW  
> subject: Establishing Priorities  
> category: MOC

## 題目

四位病人抵達緊急照護診所。護理師應首先評估哪一位病人？

## 選項

1. 一位兩天前開始有低度發燒和鼻塞的個案
2. 一位要求續領處方降血壓藥物且無其他症狀的個案
3. 一位在運動受傷後腳踝扭傷的個案，疼痛評分為6分（0-10分量表）
4. 一位新發生呼吸急促且難以說出完整句子的病人 **✔ 正確答案**

**正確答案: 4**

## 解析

呼吸道及呼吸問題優先處理。新發生的呼吸急促且無法說出完整句子，暗示呼吸窘迫，需要立即評估。其他病人需要照護，但未顯示出相同的立即性威脅。

## 深入解析

臨床判斷
利用病人線索、時間點、檢驗數據及安全風險，選擇最符合檢傷分類呼吸優先的回應。

記憶提示
將最強的線索群組與最安全的護理判斷配對。

KR vs US
NCLEX 題目獎勵基於線索的優先思考，而非孤立的回憶。

## 臨床情境

臨床實務指引
對於檢傷分類呼吸優先，將完整的線索模式與病人當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意事項
當完整情境改變了優先順序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **檢傷分類** — 根據評估和治療需求的緊迫性對病人進行分類。
- **呼吸窘迫** — 呼吸作功增加，可能威脅氧合作用。
- **優先順序設定** — 根據風險和病人穩定性，選擇最緊急的護理行動。

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