— 照護管理 · MEDIUM · MCQ —
護理師照護一位接受腹部手術的術後病人，病人主訴腹痛 7/10 及噁心。護理師應優先採取哪項措施？
A nurse is caring for a post-operative client who underwent abdominal surgery. The client reports abdominal pain rated 7/10 and nausea. Which action should the nurse take first?
- AOffer an antiemetic medication提供止吐藥
- BCheck the surgical dressing for drainage檢查手術傷口敷料是否有滲出液
- CAssess the client's vital signs評估客戶的生命徵象
- DAdminister prescribed pain medication✓ 正解給予處方止痛藥
— Explanation · 中文詳解 —
根據疼痛管理的原則，疼痛是「第五個生命徵象」。對於腹部術後病人，劇烈疼痛（7/10）會限制其深呼吸、咳嗽及下床活動，進而增加肺塌陷（atelectasis）及血栓形成的風險。因此，優先給予止痛藥以緩解疼痛，使病人能參與後續的術後復健活動，是護理師的首要任務。雖然評估生命徵象與傷口也很重要，但若病人處於劇痛狀態，其生理壓力反應會加劇，需優先處理。
Pain is considered the fifth vital sign, and uncontrolled postoperative pain can inhibit deep breathing and mobility, increasing the risk of complications like atelectasis and thromboembolism. Therefore, administering prescribed analgesics is the priority intervention to relieve suffering and facilitate participation in essential postoperative rehabilitation activities.