— 降低風險 · EASY · MCQ —
護理師照護一位闌尾切除術後的病人，下列哪項發現最需要立即回報外科醫師？
A nurse is caring for a client post-appendectomy. Which finding is the most critical to report to the surgeon immediately?
- ASerosanguineous drainage on the dressing敷料上有漿血性滲出液
- BPain rated 6/10 at the incision site切口處疼痛評分 6/10
- CAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- DRigid, board-like abdomen✓ 正解腹部僵硬如木板
— Explanation · 中文詳解 —
術後腹部變得僵硬如木板（board-like abdomen）是腹膜炎的徵兆，通常指示縫合處滲漏或發生嚴重感染，可能危及生命，必須立即處置。A 為常見術後腸蠕動減慢，A 為正常傷口分泌物，B 為術後常見疼痛，均非首要急症。
A rigid, board-like abdomen is a critical sign of peritonitis or intra-abdominal hemorrhage, indicating a surgical emergency that requires immediate notification of the surgeon. While moderate pain, serosanguineous drainage, and absent bowel sounds are expected findings shortly after abdominal surgery, they do not pose the same immediate life-threatening risk.
✦ 台美臨床差異
美台兩地護理師對腹膜炎徵象的臨床警覺性均極高，須立即通報醫師以安排緊急手術。