一位病人剛結束腹部手術,下列哪一項評估結果是護理師需優先處理的?
A nurse is caring for a client who is post-operative following an abdominal surgery. Which assessment finding should the nurse prioritize?
- ARespiratory rate 8 breaths/min✓ 正解呼吸速率 8 次/分
- BAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- CBlood pressure 100/60 mmHg血壓 100/60 mmHg
- DPresence of sanguineous drainage on the dressing敷料上有血性滲出物
依據 ABC 原則(呼吸、循環、氣道),呼吸抑制(RR < 12 次/分)是立即威脅生命的徵象。腹部手術後病人常因麻醉藥物或鎮靜劑殘餘導致呼吸抑制,這需護理師優先處理(如刺激個案、通知醫師)。Absent bowel sounds 是術後常見現象,非緊急,Sanguineous drainage 雖需注意,但不如呼吸抑制緊急。
According to the ABC principle (airway, breathing, circulation), respiratory depression (RR < 12 breaths/min) is an immediately life-threatening sign. After abdominal surgery, residual anesthetic or sedative agents often cause respiratory depression that requires the nurse's priority management (such as stimulating the client and notifying the physician). Absent bowel sounds are a common postoperative finding and not urgent; sanguineous drainage warrants attention but is less urgent than respiratory depression.