護理師照護一名人工髖關節置換術後病人。下列哪項評估發現需要立即護理介入，以降低手術併發症風險？
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which assessment finding requires immediate nursing intervention to reduce the risk of surgical complications?
- AThe client is using an incentive spirometer every 2 hours病人每 2 小時使用誘發性肺量計
- BCalf pain and tenderness in the operative leg✓ 正解手術側腿部的小腿疼痛和壓痛
- CClear yellow drainage on the surgical dressing手術敷料上有清澈黃色引流液
- DPatient reports pain of 4/10 on the numeric rating scale病人報告數字評分量表疼痛程度為 4/10
下肢手術後的深層靜脈栓塞（DVT）是極高風險併發症。小腿疼痛與壓痛是 Homans' sign 陽性的表現，暗示可能存在栓子，若栓子脫落流向肺部將導致嚴重的肺栓塞（PE），威脅生命安全。護理師應評估其脈搏、膚色、溫度，並預備執行抗凝血治療醫囑及限制下肢活動，防止血栓進一步移動。與此相比，傷口滲出清澈黃色液體多為正常組織癒合現象；疼痛 4/10 屬於臨床可接受範圍，給予止痛藥即可；每兩小時使用誘發性肺量計是預防肺部併發症的正確措施，均不需緊急介入。
Calf pain and tenderness in the operative leg are classic signs of deep vein thrombosis (DVT), which poses a life-threatening risk of pulmonary embolism if the clot dislodges. This finding requires immediate intervention, whereas serous drainage, moderate pain, and incentive spirometry use are expected or positive postoperative findings.
在美國，這類病人術後會被納入嚴謹的 DVT 預防 Protocol，護理師評估後會直接啟動抗凝血藥物或機械壓迫治療；台灣醫院較常依賴病房常規化驗與醫師巡診，護理師的自主判斷空間與配套處置較受限於醫師書面醫囑。