一位經驗豐富的外科護理師接收了一名剛進行完大規模胃部分切除術、直接從麻醉恢復室送來的病患。在將病患安置於病房後十五分鐘，病患開始大量流汗、焦躁不安且出現混亂。目前的生命徵象顯示血壓為 85/50 mmHg，心跳 135 次/分。下列哪項行動代表護理師必須執行的最關鍵立即優先任務？
An experienced surgical nurse receives a client arriving directly from the Post-Anesthesia Care Unit (PACU) following an extensive partial gastrectomy. The PACU handover reports stable vital signs. Fifteen minutes after settling the client into the room, the client becomes profusely diaphoretic, restless, and confused. The current vital signs reveal BP 85/50 mmHg and HR 135 bpm. Which action represents the most critical immediate priority for the nurse to perform?
- ADraw and send stat comprehensive metabolic panel and complete blood count lab values immediately to check for occult bleeding.立即抽取並送檢全套代謝指數及全血細胞計數，以檢查是否有隱蔽性出血。
- BAssess the surgical incisional dressing site and check underneath the client's back specifically for massive pooling hemorrhage.✓ 正解評估外科切口敷料部位，並特別檢查病患背部下方是否有大量積血。
- CVerify exactly when the client last received an injection of strong intravenous opioid pain medications in the PACU.確認病患在麻醉後護理室 (PACU) 最後一次接受強效靜脈類阿片止痛藥注射的確切時間。
- DIncrease the scheduled continuous intravenous normal saline infusion rate drastically and instantly page the surgeon.大幅增加預定持續輸注的生理食鹽水速率，並立即通知外科醫師。
本題測驗護理過程 (Nursing process) 應用於急性緊急狀況與優先順序。病患術後從穩定突然爆發出「流汗、煩躁、低血壓、極度心搏過速」，這是絕對且經典的『急性低血容積休克 / 術後內出血』。面對這種致命急症，依據護理過程 (ADPIE)，第一功能永遠是迅速展開『關鍵的生理評估 (Assessment)』來確定出血點！護士最該做的就是查看傷口敷料是否被大量鮮血浸透，並且「把手伸到病患背後摸」，因為很多時候出血不會往上浮出，而是遵循重力流到病患背後的床單底層形成了一大灘血泊（選 B 正確）。
This question tests the application of the nursing process to acute emergencies and prioritization. The client, having gone from stable to suddenly developing diaphoresis, restlessness, hypotension, and severe tachycardia after surgery, is exhibiting an absolutely classic presentation of acute hypovolemic shock secondary to postoperative internal hemorrhage. Facing this life-threatening emergency, according to the nursing process (ADPIE), the first function is always to rapidly perform a focused physiological assessment to identify the bleeding source. What the nurse must do is examine the surgical dressing for soaking with blood and reach beneath the client's back, because in many cases blood does not pool upward but follows gravity to the dependent area, forming a large pool of blood underneath the client (option B is correct).
世界級術後大出血起手式：「檢查傷口與背後」。千萬不要忘記血會往下流到病人背後，這是必考細節。