護理師照顧傷口病人，哪項評估結果是感染的徵象？
A nurse is caring for a client with a wound. Which assessment finding is a sign of infection?
- APurulent, malodorous drainage✓ 正解膿性且有異味的引流液
- BPink-tinged serous drainage帶有粉紅色的漿液性引流液
- CPresence of granulation tissue存在肉芽組織
- DClear, watery drainage清澈、水樣的引流液
傷口評估是護理師的基本職責，評估重點在於辨識感染徵象。健康的傷口癒合過程會展現粉紅色的肉芽組織，且分泌物應由漿液性逐漸減少。當傷口出現膿性分泌物（Purulent drainage）且伴隨惡臭（Malodorous），通常代表細菌增殖與發炎反應加劇，這是臨床上評估感染的關鍵指標。護理師應評估傷口周圍是否有紅（Erythema）、腫（Edema）、熱（Heat）與疼痛（Pain）等典型感染徵象。
Wound assessment is a basic nursing responsibility, with the focus on identifying signs of infection. A healthy healing wound shows pink granulation tissue, and drainage should gradually decrease from a serous nature. When the wound shows purulent drainage with a foul odor (malodorous), it usually indicates bacterial proliferation and an intensifying inflammatory response, which are key clinical indicators of infection. The nurse should assess for the classic signs of infection around the wound, including erythema, edema, heat, and pain.