— 降低風險 · EASY · MCQ —
護理師照護一位腹部術後病人。下列哪項評估結果需要立即介入？
A nurse is caring for a client who is post-operative following an abdominal surgery. Which assessment finding requires immediate intervention?
- ASerosanguineous drainage on the dressing敷料上有漿液血性滲液
- BAbsence of bowel sounds in all quadrants各象限均無腸鳴音
- CHeart rate of 115 bpm✓ 正解心率为115次/分鐘
- DPatient reporting 4/10 pain病人報告疼痛程度為4/10
— Explanation · 中文詳解 —
術後評估重點在於偵測早期休克徵兆。心搏過速（Tachycardia）通常是出血、低血容性休克（Hypovolemic Shock）、疼痛或缺氧的代償性反應。當病人心跳達到 115 bpm，代表生理系統正處於壓力下，必須立即採取介入措施，如評估傷口出血量、測量血壓、檢查末梢循環及通知醫師。這是 ABC（Airway, Breathing, Circulation）原則中循環評估的優先事項。
Post-operative assessment focuses on early signs of shock. Tachycardia (heart rate of 115 bpm) is often a compensatory response to bleeding, hypovolemia, hypoxia, or pain. The nurse must immediately assess for hemorrhage, blood pressure, perfusion, and notify the provider. Moderate pain, normal serosanguineous drainage, and transient post-op ileus are expected findings.