一位外科護理師接收一位剛完成胃部分切除術、直接由麻醉恢復室(PACU)送來的病人。PACU 交接時報告生命徵象穩定。在安置病人後 15 分鐘,病人出現大量出汗、躁動與意識混亂,生命徵象為 BP 85/50 mmHg、HR 135 次/分。下列哪項行動為護理師此時的首要優先處置?
A surgical nurse receives a client arriving directly from the Post-Anesthesia Care Unit (PACU) following a partial gastrectomy. The PACU handover reports stable vital signs. Fifteen minutes after settling the client into the room, the client becomes profusely diaphoretic, restless, and confused. Current vital signs reveal BP 85/50 mmHg and HR 135 bpm. Which action is the most critical immediate priority for the nurse?
- AInspect the surgical incision dressing and check underneath the client's back for pooling hemorrhage檢查手術切口敷料，並檢查病人背部下方是否有積血正確答案
- BIncrease the IV normal saline infusion rate and immediately notify the surgeon增加靜脈注射生理食鹽水的輸注速率，並立即通知外科醫師
- CDraw and send stat CBC and CMP to evaluate for occult bleeding立即抽取並送驗全血球計數（CBC）和綜合代謝檢查（CMP），以評估隱蔽性出血
- DVerify when the client last received an IV opioid dose in the PACU確認病人在麻醉恢復室（PACU）最後一次接受靜脈注射鴉片類藥物的時間
- A檢查手術切口敷料，並檢查病人背部下方是否有積血
本題評估護理過程(Nursing process)在急性術後狀況的應用與優先順序。病人術後突發大量出汗、躁動、混亂、低血壓(BP 85/50 mmHg)與顯著心搏過速(HR 135 次/分),為急性低血容性休克(hypovolemic shock)合併術後內出血的典型表現。依據護理過程(ADPIE),在介入(Intervention)前必須先完成針對性的評估(Assessment)以辨識出血源頭。護理師應立即檢查手術切口敷料是否被血液浸透,並依重力原則,將手伸至病人背部及床單下方,確認是否有積血(pooling),此處常因重力導致血液聚積而被忽略。選項 B 增加輸液與通報醫師雖為必要的後續處置,但缺乏評估資料下無法提供醫師完整資訊;選項 C 抽血檢驗結果無法即時呈現,且失去評估時機;選項 D 鴉片類藥物過量通常表現為心跳變慢與呼吸抑制,與本病人代償性心搏過速不符。
- A · 正確答案檢查手術切口敷料，並檢查病人背部下方是否有積血
直接檢查手術切口並觸診身體下垂的背部區域以尋找積血,為懷疑術後出血時最優先的安全評估,能即時辨識出血源。
- B增加靜脈注射生理食鹽水的輸注速率，並立即通知外科醫師
積極輸液與聯絡外科醫師為必要介入,但在介入前必須先進行針對性評估以辨識出血部位,才能提供醫師具體資訊以利後續處置。
- C立即抽取並送驗全血球計數（CBC）和綜合代謝檢查（CMP），以評估隱蔽性出血
將血液檢體送至實驗室會產生顯著的時間延遲,當下迫切需要直接觀察是否有臨床出血,故視覺評估優先。
- D確認病人在麻醉恢復室（PACU）最後一次接受靜脈注射鴉片類藥物的時間
鴉片類藥物過量典型表現為呼吸抑制與心跳變慢,與本病人心搏過速及代償性休克表現不符。
世界級術後大出血起手式：「檢查傷口與背後 (Check dressing and under the client)」。千萬不要忘記血會往下流到病人背後，這是國考與急診防護的必考細節。
English explanation
Option A is correct because profuse diaphoresis, restlessness, confusion, blood pressure of 85/50 mmHg, and heart rate of 135 beats/min after surgery indicate acute hypovolemic shock with postoperative internal bleeding. Under the nursing process, the nurse completes a focused assessment before intervention to identify the bleeding source. The nurse should immediately inspect the incision dressing for saturation and check beneath the client's back and bed linens for pooled blood, which gravity can conceal. Option B is not selected as the immediate priority because increasing normal saline and notifying the surgeon are necessary subsequent actions, but the nurse first needs assessment findings to provide complete information. Option C is incorrect because stat blood test results are not immediate and obtaining them loses the opportunity for prompt focused assessment. Option D is incorrect because opioid overdose usually causes bradycardia and respiratory depression, which do not fit this client's compensatory tachycardia.
最近修訂：2026-10-06