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
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.