護理師正在照護一位腹部手術後 6 小時的病人。護理師發現病人的心率從 82 bpm 增加到 110 bpm，血壓從 124/78 mmHg 下降到 94/60 mmHg。護理師應首先採取哪項行動？
A nurse is caring for a client who is 6 hours post-abdominal surgery. The nurse notes that the client's heart rate has increased from 82 bpm to 110 bpm, and the blood pressure has decreased from 124/78 mmHg to 94/60 mmHg. Which action should the nurse take first?
- APlace the client in a high Fowler’s position將病患置於高福勒氏臥位
- BIncrease the IV fluid rate according to standing orders依常規醫囑增加靜脈輸液速率
- CAdminister the prescribed PRN pain medication給予處方之備用止痛藥物
- DAssess the surgical site for signs of hemorrhage✓ 正解評估手術部位是否有出血跡象
此題的核心在於術後併發症的早期識別與風險降低。病人的心率上升且血壓下降（心搏過速伴隨低血壓），是低血容性休克（Hypovolemic shock）或術後出血的典型徵兆。根據護理程序（Nursing Process），在介入之前必須先進行評估（Assessment）。檢查手術部位可以立即確認是否有外出血，這對於決定後續的醫療介入至關重要。雖然給予液體（B）可能是必要的處置，但「評估」永遠是護理診斷和行動的第一步。疼痛（C）通常會使血壓升高而非降低。高處坐臥位（A）對呼吸有幫助，但對低血壓病人來說可能導致腦部血流減少，應考慮抬高下肢。
The core of this question is the early recognition of postoperative complications and risk reduction. The client's increased heart rate and decreased blood pressure (tachycardia with hypotension) are typical signs of hypovolemic shock or postoperative hemorrhage. According to the nursing process, assessment must precede intervention. Examination of the surgical site can immediately confirm whether external bleeding is present, which is essential for determining the subsequent medical intervention. Although administering fluids (B) may also be necessary, assessment is always the first step in nursing diagnosis and action. Pain (C) usually raises blood pressure rather than lowering it. High Fowler's position (A) may help with breathing, but in a hypotensive client it can decrease cerebral blood flow; elevating the legs should be considered instead.
在美國，RN 被賦予高度的臨床判斷責任，必須在通報醫師前完成初步評估（如檢查傷口、引流管）。台灣臨床環境中，護理師通常會與醫師維持極近距離的溝通，但在 NCLEX 邏輯中，護理評估（Assess）始終優先於通知或執行醫囑。