— 降低風險 · MEDIUM · MCQ —
護理師照護一位剛完成心導管檢查返回病房的病人。下列哪項評估發現需要立即通知醫師？
A nurse is caring for a client who has just returned to the unit following a cardiac catheterization. Which assessment finding requires immediate notification of the provider?
- AA hematoma is forming at the catheter insertion site✓ 正解導管插入處形成血腫
- BThe client reports mild discomfort at the insertion site病人報告插入處有輕微不適
- CThe client has a blood pressure of 110/70 mmHg病人的血壓為 110/70 mmHg
- DThe pedal pulse is 1+ on the affected extremity患側肢體的足背動脈搏動為 1+
— Explanation · 中文詳解 —
心導管術後血腫（Hematoma）可能提示穿刺部位出血或假性動脈瘤，若未及時處理可能導致周邊循環受阻，因此需立即報告。1+ 足背脈搏需持續監測但若對側正常則屬術後常見現象。輕微不適屬預期範圍，血壓穩定均在正常區間。
The formation of a hematoma at the catheter insertion site is a critical finding that may indicate active bleeding or vascular compromise, such as a pseudoaneurysm. This requires immediate notification of the provider to prevent further complications like peripheral circulatory obstruction.
✦ 台美臨床差異
美台臨床對於術後血腫評估標準一致，皆需依循SBAR溝通模式向醫師報告。