— 生理適應 · EASY · MCQ —
護理師照護一位手術傷口出現化膿引流物與紅腫的病人。應優先採取何種行動？
A nurse is caring for a client with a recent surgical wound that is showing signs of purulent drainage and erythema. Which action should the nurse take first?
- AAdminister the prescribed analgesic給予處方止痛藥
- BApply a topical antibiotic ointment塗抹局部抗生素藥膏
- CClean the wound with sterile saline用無菌生理食鹽水清潔傷口
- DObtain a wound culture✓ 正解取得傷口培養檢體
— Explanation · 中文詳解 —
當傷口出現感染跡象（化膿、紅腫）時，依據醫療指引，應先進行傷口培養以確立病原菌，確保後續抗生素治療的準確性。若先進行清潔可能會改變傷口表面的細菌菌落，影響培養結果的準確度。因此，在進行任何治療性處置前，應優先採集檢體。
When a wound shows signs of infection (purulent drainage, erythema), clinical guidelines indicate that a wound culture should be obtained first to identify the causative organism and ensure accurate antibiotic therapy. Cleaning the wound first could alter the bacterial colonies on the wound surface and reduce the accuracy of the culture result. The specimen should therefore be collected before any therapeutic intervention.
✦ 台美臨床差異
台美皆遵循無菌原則，但在美國護理師依醫囑進行培養之自主性較高。