— 降低風險 · MEDIUM · SATA —
下列哪些病人評估結果需要護理師立即通知醫師？（選所有適合的）
Which of the following client assessments requires immediate notification of the provider by the nurse? (Select all that apply.)
- APost-thyroidectomy client with inspiratory stridor✓ 正解甲狀腺切除術後病人出現吸氣性喘鳴
- BPost-cataract surgery client reporting mild itching白內障切除術後病人主訴輕微搔癢
- CPost-appendectomy client with absent bowel sounds 2 hours post-op闌尾切除術後病人，術後 2 小時腸鳴音消失
- DClient on warfarin with an INR of 4.5✓ 正解服用華法林的病人，INR 為 4.5
- EPost-cardiac catheterization client with a weak pedal pulse on the affected side✓ 正解心臟導管術後病人，患側足背脈搏微弱
— Explanation · 中文詳解 —
甲狀腺切除後吸氣性喘鳴代表喉頭水腫，有氣道阻塞風險；INR 4.5 超過治療範圍，出血風險大；心導管後患肢脈搏減弱暗示栓塞或供血不足。輕微癢在眼科手術後常見；術後 2 小時腸音缺失屬於麻醉後正常現象。
Inspiratory stridor after thyroidectomy indicates potential airway obstruction from laryngeal edema, requiring immediate intervention. An INR of 4.5 exceeds the therapeutic range, significantly increasing bleeding risk, and a weak pedal pulse after cardiac catheterization suggests vascular compromise or embolism.
✦ 台美臨床差異
美台護理評估標準一致，皆將呼吸道與末梢循環異常列為危急重症指標。