# 護理師剛接獲 4 位病人的交班。應先評估哪位病人？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522686&lang=zh-tw  
> language: zh-TW  
> subject: Establishing Priorities  
> category: MOC

## 題目

護理師剛接獲 4 位病人的交班。應先評估哪位病人？

## 選項

1. 甲狀腺切除術後 6 小時，主訴吞嚥時有緊迫感的病人 **✔ 正確答案**
2. 髖關節置換術後 1 天，疼痛分數從 4 分升至 7 分的病人
3. 肺炎病人，未用氧氣下血氧飽和度為 92%
4. 肝硬化病人，今日腹圍增加 2 公分

**正確答案: 1**

## 解析

甲狀腺切除術後吞嚥緊迫感可能表示頸部血腫壓迫呼吸道。呼吸道風險優先於疼痛、邊緣性血氧飽和度及緩慢的體液變化。

## 深入解析

快速解答
先看甲狀腺切除術後主訴頸部緊迫感的病人。

為什麼這是正確的
頸部封閉空間出血會在血氧飽和度下降前壓迫呼吸道。吞嚥緊迫感是早期主訴，等待測量值變化等於在問題確立後才處理。

簡單比喻或心智圖像
這就像密封箱內水位上升：外表看似平靜，直到箱子破裂。此圖像說明隱藏的進展，且不表示其他病人可無限期穩定。

記憶掛鉤
頸部手術後，緊迫感就是呼吸道主訴。

NCLEX 決策規則
將可能的呼吸道威脅排在疼痛、邊緣數值及緩慢趨勢之前。封閉手術空間的症狀在證明為其他問題前，一律視為呼吸道問題。

為什麼其他選項是錯的
疼痛加劇、血氧飽和度 92% 及腹圍增加都值得在本輪評估，但無一會在數分鐘內威脅呼吸道。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]MedlinePlus: Thyroid Gland RemovalU.S. National Library of Medicine

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