一位病人腹部手術後 24 小時，護理師觀察到傷口邊緣裂開。此時應優先採取的措施為何？
A nurse is caring for a client who is 24 hours post-operative after an abdominal surgery. The nurse notes the client's wound edges are pulling apart. Which action is the priority?
- APrepare the client for immediate re-suturing準備病人立即重新縫合
- BAssess the wound for signs of infection評估傷口是否有感染跡象
- CCover the wound with sterile saline-soaked gauze✓ 正解以生理食鹽水浸濕的無菌紗布覆蓋傷口
- DApply an abdominal binder應用腹部束帶
傷口裂開（Dehiscence）屬外科急症，首要任務是保持傷口濕潤並防止臟器外露與感染。使用生理食鹽水濕敷可防止組織乾燥並避免沾黏。B 應先穩定情況；C 束腹帶會增加腹壓；D 評估感染固然重要，但穩定傷口以保護臟器為第一優先。
Wound dehiscence is a surgical emergency. The priority is to keep the wound moist and prevent evisceration and infection. Applying sterile saline-soaked gauze prevents tissue desiccation and adhesion. Option A requires that the situation be stabilized first; option D (abdominal binder) increases intra-abdominal pressure; option B (assessing for infection) is important, but stabilizing the wound to protect the viscera is the top priority.
美台臨床對於傷口裂開處理相似，均強調生理食鹽水濕敷並立即通知醫師，區別在於美國急診或加護病房護理師權限較廣，可更快進行處置。