一位外科護理師接收了剛接受胃切除術從恢復室送來的病患。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。目前血壓 85/50 mmHg，心跳 135 次/分。哪項行動代表了護理師最關鍵的診斷性評估？
An experienced surgical nurse receives a client arriving directly from the Post-Anesthesia Care Unit (PACU) following a partial gastrectomy. 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 diagnostic assessment for the nurse?
- AVerify when the client last received opioid pain medications in the PACU.確認病人在恢復室最後一次接受類阿片止痛藥的時間。
- BDraw stat blood cultures to evaluate for developing post-operative sepsis.立即抽取血液培養物以評估是否發展為術後敗血症。
- CAssess the incisional dressing site and palpate underneath the client's back for pooling blood.✓ 正解評估切口敷料部位，並觸診病人背部下方是否有積血。
- DCheck the client's bilateral pupil reactions with a penlight.使用筆形燈檢查病人雙側瞳孔反應。
本題測驗急性併發症的優先生理評估。病患術後突然出現「流汗、煩躁、低血壓、極度心搏過速」，這是經典的『低血容積休克 (Hypovolemic shock / Hemorrhage)』。護理師最該做的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」，因為出血常常會遵循重力流到病患背後的床單上積聚 (pooling)。
This item tests the priority physiological assessment for an acute postoperative complication. A patient who suddenly develops diaphoresis, restlessness, hypotension, and marked tachycardia after surgery is presenting with classic hypovolemic shock from hemorrhage. The nurse's most important action is to check whether the surgical dressing is soaked with bright red blood and to reach behind the patient and feel under them, because blood often follows gravity and pools on the bed linens behind the patient.
術後大出血起手式：「檢查傷口與背後」。血會往下流到病人背後是必考細節。