— 照護管理 · HARD · MCQ —
護理師需評估四位病人，哪一位應優先處理？
A nurse is assessing four clients. Which client needs to be evaluated first by the nurse?
- AA client with an indwelling catheter who has not voided in 4 hours留置導尿管且 4 小時未排尿的病人
- BA client with a stage 2 pressure ulcer requiring a dressing change需要更換敷料的第二期壓瘡病人
- CA client with a chest tube who has 200 mL of bright red blood in the drainage chamber in one hour✓ 正解胸管引流室一小時內有 200 mL 鮮紅血液的病人
- DA client with a potassium level of 4.8 mEq/L reporting muscle cramps鉀離子濃度為 4.8 mEq/L 並報告肌肉痙攣的病人
— Explanation · 中文詳解 —
胸管引流液突然大量（>100 mL/hr）且為鮮紅色，暗示術後急性出血，屬於危及生命之出血狀況，需優先處理。其他選項中，鉀離子 4.8 屬正常範圍（3.5-5.0），肌肉抽搐可能源於其他原因；壓瘡換藥非緊急；尿管 4 小時未有引流液需監測，但嚴重度低於急性出血。
Chest-tube drainage exceeding 100 mL/hr of bright red blood, especially the 200 mL described here, suggests active post-operative hemorrhage and requires immediate evaluation; surgical re-exploration may be necessary. A potassium of 4.8 mEq/L is within normal range. A Stage 2 ulcer dressing change is routine, and an indwelling catheter without output for 4 hours warrants investigation but is less urgent than active hemorrhage.
✦ 台美臨床差異
台美臨床對於胸管急性出血的處理流程一致，皆需優先通報外科醫師。