# 一位甲狀腺切除術後6小時的個案出現喘鳴，且呼吸費力程度增加。哪項行動是優先處置？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396608&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

一位甲狀腺切除術後6小時的個案出現喘鳴，且呼吸費力程度增加。哪項行動是優先處置？

## 選項

1. 提供溫茶以舒緩喉嚨。
2. 將個案平放並使用緊密加壓敷料。
3. 留在個案身邊，呼叫緊急援助，並準備進行緊急呼吸道處置。 **✔ 正確答案**
4. 向個案保證術後出現呼吸雜音是正常的。

**正確答案: 3**

## 解析

甲狀腺切除術後的喘鳴可能表示因水腫、出血或喉神經併發症導致的呼吸道受損。優先處置是立即提供呼吸道支持並迅速通報升級。給予保證或延遲介入可能危及生命。

## 深入解析

臨床判斷
利用個案線索、時機、檢驗數據和安全風險，選擇最符合甲狀腺切除術後呼吸道受損的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實踐指引
針對甲狀腺切除術後呼吸道受損，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
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

- **甲狀腺切除術** — 手術切除全部或部分甲狀腺。
- **喘鳴** — 一種高頻率的呼吸道聲音，可能表示上呼吸道阻塞。
- **呼吸道處置** — 維持或恢復通暢呼吸道的介入措施。

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