— 降低風險 · MEDIUM · MCQ —
病人腹部手術後 24 小時。護理師發現手術傷口發生臟器脫出。護理師的立即行動為何？
A client is 24 hours postoperative after an abdominal surgery. The nurse notes the surgical wound has eviscerated. What should be the nurse's immediate action?
- ACover the wound with a sterile, saline-soaked dressing✓ 正解以無菌生理食鹽水浸濕的敷料覆蓋傷口
- BApply a tight abdominal binder施加緊繃的腹部束帶
- CAttempt to push the organs back into the abdomen嘗試將臟器推回腹腔
- DPosition the client in a high-Fowler's position讓病人採高坐臥姿
— Explanation · 中文詳解 —
腹部手術後 24 小時發生臟器脫出 (evisceration) 是一種外科急症，表示腹腔內容物（如腸道）從手術傷口突出。此情況對病人構成感染、器官缺血及組織損傷的極高風險，因此護理師的立即行動必須以保護外露臟器、防止進一步損害為首要考量。使用無菌生理食鹽水濕敷料覆蓋是為了保持臟器濕潤，避免乾燥壞死，同時提供無菌屏障以減少感染機會。隨後應立即通知醫師，準備緊急手術介入。
Wound evisceration is a surgical emergency requiring immediate protection of exposed organs to prevent drying, ischemia, and infection. The nurse should cover the area with sterile, saline-soaked dressings to maintain moisture and sterility while notifying the provider and preparing for urgent surgical intervention.