護理師照護一位腹部手術後 6 小時的病人。下列哪項評估結果最需要立即通報醫師？
A nurse is caring for a client 6 hours post-abdominal surgery. Which assessment finding is most important to report to the healthcare provider?
- ASerosanguineous drainage on the dressing敷料上有漿液血性滲出液
- BAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- CUrine output of 100 mL over the last 4 hours過去 4 小時尿量 100 mL
- DHeart rate of 115 beats per minute✓ 正解心率 115 次/分
此題考驗護理師辨識術後早期併發症（出血或低血容休克）的能力。術後 6 小時，腸音消失（B）是正常的麻醉後現象（術後腸阻塞），通常需 24-48 小時恢復。尿量（C）為 25 mL/hr，雖接近邊緣但尚未達到每小時低於 30 mL 的警戒值，需密切觀察。傷口滲出粉紅色血水（A）在術後初期亦屬常見。然而，心搏過速（D，HR 115）是補償低血容（如內出血）的最早期徵象。在術後病人身上，心跳上升往往早於血壓下降，這代表病人可能正在經歷隱匿性出血或液體補充不足。根據風險降低原則，必須優先回報生命徵象的異常，以排除致命性的內出血。
This item tests the nurse's ability to recognize early postoperative complications (bleeding or hypovolemic shock). At 6 hours after surgery, absent bowel sounds (B) is a normal post-anesthetic finding (postoperative ileus) that usually resolves within 24-48 hours. Urine output (C) of 25 mL/hr is borderline but has not yet reached the threshold of <30 mL/hr that triggers alarm and requires close monitoring. Pink-tinged wound drainage (A) is also common in the early postoperative period. However, tachycardia (D, HR 115) is the earliest compensatory sign of hypovolemia (such as internal bleeding). In postoperative clients, an increased heart rate typically precedes a drop in blood pressure, indicating that the client may be experiencing occult bleeding or inadequate fluid replacement. Based on risk reduction principles, abnormalities in vital signs must be reported first to rule out life-threatening internal bleeding.
美國 NCLEX 強調早期預警系統（EWS）的概念，心搏過速常被視為敗血症或出血的早期指標；台灣臨床護理師有時會先觀察或給予液體補充，但在國考邏輯中，『通報並尋求診斷』是降低風險的首選。