— 基本照護與舒適 · MEDIUM · MCQ —
一位病人的傷口敷料被血液滲濕，護理師優先採取哪項行動？
A client has a wound dressing that is saturated with blood. What is the nurse's priority action?
- ARemove the dressing to inspect the wound移除敷料以檢查傷口
- BReinforce the existing dressing✓ 正解加強現有敷料
- CCall the surgeon immediately立即通知外科醫師
- DApply a new, clean dressing over the existing one在現有敷料上覆蓋新的乾淨敷料
— Explanation · 中文詳解 —
當傷口敷料滲血（Saturation），首要行動是「加強敷料（Reinforce）」。直接移除敷料會導致已經形成的纖維蛋白凝塊（Fibrin clot）被撕除，引發再次出血，延緩癒合。護理師應在原有敷料上覆蓋新的敷料，並觀察滲血速度。若出血持續且敷料仍迅速被浸濕，則應加壓止血並立即通知外科醫師處理。
When a wound dressing becomes saturated with blood, the priority action is to 'reinforce' the dressing. Directly removing the dressing disrupts the fibrin clot that has already formed, causes rebleeding, and delays healing. The nurse should apply additional dressing over the existing one and observe the rate of bleeding. If bleeding persists and the dressing continues to be rapidly saturated, pressure should be applied for hemostasis and the surgeon notified immediately.