— 降低風險 · EASY · MCQ —
護理師照顧一位放置 Jackson-Pratt 引流管的術後病人，下列哪種發現需要立即處理？
A nurse is caring for a postoperative client with a Jackson-Pratt drain. Which assessment finding requires immediate intervention?
- AThe tubing is kinked and lying under the client's body✓ 正解管路扭曲並壓在病人身體下方
- BThe incision site has a small amount of dried blood切口處有少量乾涸的血跡
- CThe drainage container is half-full with serosanguineous fluid引流容器半滿，充滿漿液血性液體
- DThe drain is compressed and the stopper is secure引流管已壓縮且塞子固定牢固
— Explanation · 中文詳解 —
引流管受壓或扭曲會導致引流不暢，造成液體滯留在體內，增加術後感染及形成血腫的風險。護理師應確保管路通暢，避免受壓。C 為正常現象；D 是正確的維持負壓方式；B 少量乾血漬為術後常見狀況，無須過度反應。
A drain that is compressed or kinked will not drain adequately, causing fluid to accumulate in the body and increasing the risk of postoperative infection and hematoma formation. The nurse should ensure tubing patency and avoid compression. Option C is a normal finding; Option D is the correct way to maintain negative pressure; Option B, a small amount of dried blood, is a common postoperative finding and does not warrant overreaction.
✦ 台美臨床差異
台美臨床對引流管監測原則一致，均強調維持系統密閉性與負壓狀態。