護理師照護一位剛完成腹部手術的病人，下列哪項評估結果需要立即介入？
A nurse is caring for a client who has just returned from an abdominal surgery. Which assessment finding requires immediate intervention?
- AClient report of 3/10 incisional pain客戶報告切口疼痛為 3/10
- BPulse rate of 110 beats/min and blood pressure of 90/60 mmHg✓ 正解脈搏速率 110 次/分，血壓 90/60 mmHg
- CHypoactive bowel sounds in all four quadrants四個象限腸蠕動音減弱
- DBlood-tinged drainage on the surgical dressing手術敷料上有血性滲液
術後低血壓伴隨心搏過速是低血容性休克（Hypovolemic Shock）的典型徵兆。當心跳大於 100 bpm 且收縮壓顯著下降時，代表病人可能因術中或術後出血導致循環血量不足。這屬於危急情況，需立即通知醫師、監測生命徵象、進行輸液復甦並評估傷口出血量。相比之下，輕微滲血或腸蠕動音減弱屬於術後可預期的恢復過程。
Postoperative hypotension combined with tachycardia is a classic sign of hypovolemic shock. When the heart rate exceeds 100 bpm and the systolic blood pressure drops significantly, the patient may have inadequate circulating volume due to intraoperative or postoperative bleeding. This is a critical situation that requires immediate notification of the provider, monitoring of vital signs, fluid resuscitation, and assessment of wound bleeding. In comparison, minor drainage or hypoactive bowel sounds are expected findings during postoperative recovery.