護理師評估一位腹部手術後病人的情況，下列何種發現需要立即介入？
A nurse is assessing a client who is postoperative following abdominal surgery. Which finding requires immediate intervention?
- ASlight serous drainage on the dressing.敷料上有少量漿液性滲出物
- BClient reporting incisional pain rated 5/10.病人報告切口疼痛程度為 5/10
- CRedness and swelling at the surgical incision site with purulent drainage.✓ 正解手術切口部位紅腫並伴有膿性分泌物
- DA temperature of 38.5°C (101.3°F).體溫 38.5°C (101.3°F)
腹部手術後的恢復期，病人可能出現各種術後反應，但護理師必須識別可能導致嚴重併發症的警訊。選項 C 所描述的「紅腫、腫脹伴隨膿性分泌物」是典型的傷口感染徵兆，可能進一步發展為傷口裂開（dehiscence）、深層組織感染，甚至引發敗血症（sepsis）。這種情況需要立即介入，包括通知醫師、無菌處理傷口、給予抗生素等，以防止病情惡化。其他選項雖然需要監測，但相對不具立即的生命危險。
During the postoperative recovery period after abdominal surgery, the client may exhibit various postoperative responses, but the nurse must recognize warning signs that may lead to serious complications. The redness, swelling, and purulent drainage described in option C are typical signs of wound infection, which can progress to wound dehiscence, deep tissue infection, and even sepsis. This situation requires immediate intervention, including notifying the physician, performing sterile wound care, and administering antibiotics, to prevent deterioration. The other options require monitoring but do not pose an equally immediate life-threatening risk.
無顯著差異。手術傷口感染的臨床表現及處理原則在台灣和美國是相同的。護理師皆需具備辨識感染徵象的能力，並依循標準的臨床處置流程，包括通知醫師、進行傷口評估與處理、必要時給予抗生素等。