# 幾名個案在大樓倒塌後送達。檢傷分類護理師應將哪一位個案歸類為需要立即處置？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397126&lang=zh-tw  
> language: zh-TW  
> subject: Establishing Priorities  
> category: MOC

## 題目

幾名個案在大樓倒塌後送達。檢傷分類護理師應將哪一位個案歸類為需要立即處置？

## 選項

1. 一位前臂開放性骨折且可觸及橈動脈搏動的案主。
2. 一位可自行行走，主訴焦慮和輕微擦傷的案主。
3. 一位呼吸道重新定位後仍無呼吸的案主。
4. 一位嚴重呼吸窘迫且微血管回填時間為 4 秒的案主。 **✔ 正確答案**

**正確答案: 4**

## 解析

在災難檢傷分類中，立即處置的優先對象為有危及生命但可能有存活機會的呼吸道、呼吸或循環問題的個案。嚴重呼吸窘迫合併延遲灌流需要立即介入。在許多災難檢傷分類系統中，呼吸道重新擺位後仍無呼吸的個案被歸類為期待性。

## 深入解析

臨床判斷
使用案主線索、時間點、檢驗數據和安全風險，選擇最符合大量傷患檢傷分類的回應。

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，而非孤立的回憶。

## 臨床情境

臨床實踐指引
對於大量傷患檢傷分類，將完整的線索模式與案主當前的穩定性、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級或安全性時，不要根據單一孤立的線索選擇行動。

## 重要概念

- **災難檢傷分類 (Disaster Triage)** — 在大量傷患事件中，為最大化存活率而對案主進行的快速分類。
- **立即處理類別 (Immediate Category)** — 針對有生命危險但可治療問題的檢傷優先級。
- **微血管回填 (Capillary Refill)** — 一種快速評估周邊灌流的方法。

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