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降低風險 · MEDIUM · SATA

護理師照護一位腸道切除術後的病人。若出現哪些情況,護理師應立即通知醫師?(選所有適合的)

A nurse is caring for a client who is postoperative following a bowel resection. The nurse should notify the provider if which of the following is assessed? (Select all that apply.)

  • AAbsent bowel sounds for 8 hours post-op
    術後 8 小時無腸鳴音
  • BBright red drainage of 150 mL in the NG tube✓ 正解
    NG 管內有 150 mL 鮮紅色引流液
  • CHard, board-like abdomen upon palpation✓ 正解
    觸診時腹部硬如木板
  • DPassing of flatus after 24 hours
    術後 24 小時後排出氣體
  • EFever of 101.5°F (38.6°C) and tachycardia✓ 正解
    體溫 101.5°F (38.6°C) 伴隨心搏過速
Explanation · 中文詳解

腸道切除術後,護理師需嚴密監控腹部併發症。鮮紅色引流液代表活動性出血;腹部僵硬(Board-like abdomen)是腹膜炎(Peritonitis)的典型表現,通常與吻合處滲漏有關;發燒合併心跳過速則是敗血症或嚴重感染的早期徵兆。這些發現均屬於緊急狀況,必須立即通知醫師處理,以避免病情惡化導致生命危險。

After bowel resection, the nurse must closely monitor for abdominal complications. Bright red drainage indicates active bleeding; a board-like abdomen is a typical presentation of peritonitis, often associated with anastomotic leak; fever with tachycardia is an early sign of sepsis or severe infection. These findings are emergencies and must be reported to the provider immediately to prevent life-threatening deterioration.

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