— 降低風險 · HARD · SATA —
護理師為腹部手術後病人進行術後評估，哪些情況需要立即採取行動？（選所有適合的）
A nurse is performing a postoperative assessment for a client who had abdominal surgery. Which findings require immediate intervention? (Select all that apply.)
- AHeart rate 110 bpm✓ 正解心率 110 次/分
- BUrine output 20 mL/hr over the last 2 hours✓ 正解過去 2 小時尿量為 20 mL/小時
- CReports of mild incision pain主訴切口輕微疼痛
- DBlood-soaked dressing✓ 正解敷料被血液浸透
- ERestlessness and confusion✓ 正解煩躁不安與意識混亂
— Explanation · 中文詳解 —
術後評估（Postoperative assessment）的核心在於監測是否有休克、出血或呼吸循環衰竭的跡象。心搏過速（Tachycardia）、尿量減少（Oliguria）、傷口大量出血（Hemorrhage）以及意識改變（Altered mental status），均是早期休克的典型表現，需要立即介入處置，以避免病人進入不可逆的循環衰竭狀態。
Postoperative assessment focuses on identifying signs of shock, hemorrhage, and cardiopulmonary failure. Tachycardia, oliguria, hemorrhage from a blood-soaked dressing, and altered mental status are all classic early manifestations of shock and require immediate intervention to prevent the patient from progressing to irreversible circulatory failure.