— 生理適應 · MEDIUM · MCQ —
病人腹部手術後處於復甦室（PACU），護理師優先應關注哪項結果？
A client is in the post-anesthesia care unit (PACU) following abdominal surgery. Which finding is the nurse's priority?
- APulse oximetry 90% on supplemental oxygen✓ 正解補充氧氣下脈搏血氧飽和度為 90%
- BPain level 7/10疼痛程度 7/10
- CDrowsiness when called呼喚時嗜睡
- DHypoactive bowel sounds腸鳴音減弱
— Explanation · 中文詳解 —
復甦室（PACU）的照護核心遵循 ABC 原則（呼吸道、呼吸、循環）。病人 SpO2 為 90% 處於邊緣狀態，即便有給氧，仍顯示氣體交換功能可能受麻醉藥抑制或換氣不足影響，這是潛在的缺氧與呼吸衰竭警訊。優先處理呼吸問題是維持生命的基本要求。疼痛雖重要，但屬於穩定生命徵象後的管理項目。昏睡與腸鳴音減弱在術後初期是常見的生理反應，若無呼吸窘迫，優先級較低。
Following the ABCs of nursing care, oxygenation is the highest priority in the PACU. An SpO2 of 90% despite supplemental oxygen indicates ineffective gas exchange and potential respiratory depression from anesthesia, requiring immediate intervention. While pain and drowsiness are common postoperative findings, they are secondary to addressing life-threatening respiratory compromise.