— 降低風險 · MEDIUM · MCQ —
護理師照護一位術後病人。哪項評估發現需要立即護理介入？
A nurse is caring for a postoperative client. Which assessment finding requires immediate nursing intervention?
- ASudden onset of dyspnea✓ 正解突發呼吸困難
- BHypoactive bowel sounds腸蠕動音減弱
- CLow-grade fever低度發燒
- DPain at the incision site切口處疼痛
— Explanation · 中文詳解 —
術後突發性呼吸困難（Dyspnea）強烈懷疑為肺栓塞（PE）。PE 是嚴重的術後併發症，可能危及生命，必須立即進行氧氣給予、呼叫醫療團隊並評估生命徵象。其他如腸蠕動減弱、傷口疼痛或輕微發燒均為術後可預期的現象。
Sudden onset of dyspnea in a postoperative client raises strong suspicion of pulmonary embolism (PE). PE is a serious postoperative complication that can be life-threatening and requires immediate oxygen administration, activation of the medical team, and assessment of vital signs. Other findings such as hypoactive bowel sounds, incisional pain, or low-grade fever are all expected postoperative phenomena.
✦ 台美臨床差異
兩國對術後護理風險管理標準一致，特別是針對肺栓塞的早期辨識。