一位接受腹部子宮切除術的病人剛從恢復室（PACU）返回病房。病人的血壓從 120/80 mmHg 降至 94/52 mmHg，心率從 72 次/分增加到 110 次/分。護理師首要的行動為何？
A nurse is caring for a client who has just returned from the post-anesthesia care unit (PACU) following an abdominal hysterectomy. The client’s blood pressure has dropped from 120/80 mmHg to 94/52 mmHg, and the heart rate has increased from 72 to 110 beats/min. What is the priority nursing action?
- AIncrease the intravenous fluid infusion rate增加靜脈輸液的速率
- BAdminister the prescribed PRN pain medication給予處方上的 PRN 止痛藥物
- CPerform a focused assessment of the surgical site and vaginal bleeding✓ 正解對手術部位和陰道出血進行重點評估
- DPlace the client in the Trendelenburg position將病人置於特倫德倫堡氏臥位
此題的核心概念在於識別術後早期併發症——出血性休克。病人的生命徵象顯示典型的低血容性休克徵象（血壓下降、心率加快）。在採取介入措施（如加快點滴）之前，護理師必須先「評估（Assess）」以確定出血來源。評估手術傷口與陰道出血量是判斷是否發生內出血或外出血的關鍵。根據護理程序（ADPIE），當病人狀況改變時，應先進行評估以收集數據。雖然 A 選項能暫時穩定血壓，但若未找出出血原因，問題仍未解決；B 選項會因止痛藥（如嗎啡）進一步降低血壓；D 選項已不再被推薦為休克的首選姿勢，因其可能壓迫橫膈膜影響呼吸。
The core concept of this item is recognizing an early postoperative complication—hemorrhagic shock. The client's vital signs show typical signs of hypovolemic shock (decreased blood pressure, increased heart rate). Before taking intervention measures (such as increasing IV fluids), the nurse must first 'assess' to identify the source of bleeding. Assessing the surgical site and the amount of vaginal bleeding is the key to determining whether internal or external hemorrhage is occurring. Per the nursing process (ADPIE), when a client's condition changes, an assessment should be conducted first to gather data. Although option A may temporarily stabilize the blood pressure, without identifying the cause of bleeding, the problem remains unresolved; option B (such as morphine) would further lower the blood pressure; option D is no longer recommended as the first-line position for shock because it may compress the diaphragm and impair breathing.
在美國 NCLEX 考試中，非常強調『先評估再行動』的邏輯。在台灣臨床環境中，護理師遇到生命徵象急遽變化時，往往會與醫師同時進行點滴調整與評估，但在考題選擇上，必須優先選出能確認問題根源的評估動作。