— 生理適應 · HARD · MCQ —
一位剛結束腹部手術的病人，下列哪項評估結果最令人擔憂？
A nurse is caring for a client who has just returned from an abdominal surgery. Which finding is most concerning?
- AA heart rate of 115 bpm and cold, clammy skin✓ 正解心率115次/分且皮膚冰冷潮濕
- BIncisional pain rated at 7 out of 10切口疼痛評分為10分中的7分
- CAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- DSmall amount of serosanguineous drainage on the dressing敷料上有少量漿血性滲出液
— Explanation · 中文詳解 —
術後評估優先順序為維持生命徵象穩定。心跳過快搭配冷汗濕冷的皮膚，是早期低血容性休克的典型徵兆，極可能代表術後內出血。相較之下，腸鳴音暫時消失（麻痺性腸阻塞）是術後常見的預期結果；傷口疼痛需處理但無立即生命威脅；少許漿液性血水也是術後正常現象。
Postoperative priority is hemodynamic stability. Tachycardia with cold, clammy skin is a classic early sign of hypovolemic shock, suggesting postoperative internal bleeding. By contrast, transient absence of bowel sounds (paralytic ileus) is expected; incisional pain needs management but is not immediately life-threatening; small serosanguineous drainage is normal.
✦ 台美臨床差異
美台術後評估流程一致，皆首重循環系統之穩定，以預防術後出血性休克。