護理師照護一位腹部術後病人。下列哪項評估發現是通報醫師的最高優先級？
A nurse is caring for a postoperative client who had an abdominal surgery. Which assessment finding is the highest priority to report to the surgeon?
- AAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- BClient reports 5/10 pain level at the incision site病患報告切口處疼痛程度為 5/10
- CSerosanguineous drainage on the surgical dressing手術敷料上有漿血性滲出液
- DHeart rate of 115 beats per minute and blood pressure of 90/60 mmHg✓ 正解心率 115 次/分，血壓 90/60 mmHg
術後評估應優先處理危及循環與生命的異常數據。心搏過速合併低血壓顯示病人可能正處於出血性休克或嚴重的體液流失，必須立即評估生命徵象穩定性並通知醫師。其他選項如傷口滲液、疼痛或腸蠕動減弱均為術後預期的臨床表徵，屬於需持續監測但非立即致命的項目。
Postoperative assessment should prioritize abnormalities that threaten circulation and life. Tachycardia combined with hypotension suggests the client may be in hemorrhagic shock or experiencing severe fluid loss, requiring immediate evaluation of hemodynamic stability and notification of the provider. Other findings such as wound drainage, pain, or decreased bowel sounds are expected postoperative clinical features that require ongoing monitoring but are not immediately life-threatening.
美台臨床皆視術後生命徵象惡化為急症，但在台灣護理師通常會先確認傷口有無滲血，美國則更重視早期預警系統（EWS）評分。