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降低風險 · MEDIUM · MCQ

護理師照護一位腹部術後病人,下列哪項發現應立即報告醫師?

A nurse is providing care to a client who is post-operative following an abdominal surgery. Which of the following findings should be reported to the provider immediately?

  • ASerosanguineous drainage on the dressing
    敷料上有漿液血性引流物
  • BReport of moderate pain at the incision site
    切口處有中度疼痛的主訴
  • CSudden increase in heart rate and decreased blood pressure✓ 正解
    心跳突然加快且血壓下降
  • DAbsence of bowel sounds in all four quadrants
    四個象限均無腸鳴音
Explanation · 中文詳解

術後照護中,評估的核心指標為維持生理穩定(Physiological Stability)。當病人出現心跳加速(Tachycardia)合併血壓下降(Hypotension)時,這是休克(Shock)或內出血(Internal Hemorrhage)的典型臨床表現。這種生命徵象的改變,提示循環系統已無法維持足夠的組織灌流,屬於危急狀況,必須立即通知醫師進行急救處置,否則隨時可能演變成低血容性休克(Hypovolemic Shock)甚至器官衰竭。

The key indicator in postoperative care is maintaining physiological stability. When the patient develops tachycardia together with hypotension, this is a classic clinical presentation of shock or internal hemorrhage. This change in vital signs indicates that the circulatory system can no longer maintain adequate tissue perfusion; it is a critical situation, and the physician must be notified immediately for emergency management, otherwise it may progress to hypovolemic shock or even organ failure.

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