一位病人剛結束腹部手術，自述疼痛劇烈。護理師發現傷口敷料被鮮紅滲出液浸濕。護理師應優先採取何種行動？
A client is recovering from an abdominal surgery and reports severe pain. The nurse notes the dressing is saturated with bright red drainage. What is the priority nursing intervention?
- AMark the drainage area on the current dressing在當前敷料上標記滲出液區域
- BContact the surgeon immediately立即聯繫外科醫師
- CReinforce the dressing with additional sterile gauze使用額外無菌紗布加固敷料
- DAssess the client's vital signs✓ 正解評估病人的生命徵象
面對術後傷口滲出大量鮮紅血液，護理師的首要任務是評估病人的血液動力學狀態（Hemodynamic status），以排除低血容性休克（Hypovolemic shock）的可能。NCLEX 考題強調「評估先於介入」（Assessment before intervention），在未確認生命徵象前，無法判斷出血的嚴重程度。若病人已出現心跳加速、血壓下降，則屬於緊急醫療狀況，需立即呼叫團隊處理。
When confronted with copious bright red drainage from a postoperative wound, the nurse's first priority is to assess the patient's hemodynamic status in order to rule out hypovolemic shock. NCLEX questions emphasize 'assessment before intervention'; without confirmed vital signs, the severity of bleeding cannot be determined. If the patient is tachycardic and hypotensive, the situation is a medical emergency requiring immediate team response.
在美國臨床環境中，護理師有較高的自主權啟動快速反應小組（Rapid Response Team, RRT），若生命徵象顯示休克，護理師會直接啟動 RRT 而非僅通知主治醫師。