護理師照護一位腹部有嚴重傷口且發生腸道外露（eviscerated）的病人，護理師應首先採取哪項措施？
A nurse is caring for a client with a large abdominal wound that has eviscerated. Which nursing action should the nurse take FIRST?
- AAdminister intravenous fluids給予靜脈注射流質
- BCover the exposed organs with sterile, moist dressings✓ 正解以無菌濕敷料覆蓋外露的器官
- CPrepare the client for surgery準備病人接受手術
- DNotify the surgeon immediately立即通知外科醫師
腸道外露（evisceration）是外科手術後的重大緊急併發症。當腹壁傷口裂開且內臟器官露出時，護理師的首要目標是預防器官乾燥、感染與進一步損傷。使用無菌、生理食鹽水濕潤的敷料覆蓋，能維持器官濕潤並形成屏障，防止細菌進入。此處遵循「安全第一」與「ABC原則」中的預防感染與保護組織完整性。通知外科醫師、補充體液與準備手術是後續必要的救急步驟，但需在保護器官後立即執行。
Evisceration is a major postoperative surgical emergency. When the abdominal wound dehisces and internal organs protrude, the nurse's first goal is to prevent the organs from drying out, becoming infected, or sustaining further damage. Covering the organs with a sterile, saline-moistened dressing maintains moisture and creates a barrier that prevents bacterial entry. This follows the principles of safety first and the ABC framework, focusing on infection prevention and protection of tissue integrity. Notifying the surgeon, replacing fluids, and preparing for surgery are necessary subsequent emergency steps, but they must be performed only after the organs have been protected.