— 降低風險 · MEDIUM · MCQ —
護理師照護一位術後 2 小時腹部子宮切除術的病人，發現敷料被鮮紅色血液浸濕。護理師應優先採取何種行動？
A nurse is caring for a postoperative client who had an abdominal hysterectomy 2 hours ago. The nurse notes the surgical dressing is saturated with bright red blood. Which action is the priority?
- ANotify the surgeon immediately立即通知外科醫師
- BApply pressure to the site and assess vital signs✓ 正解對患處施加壓力並評估生命徵象
- CApply additional dressings over the site在患處上加蓋額外敷料
- DOutline the drainage with a marker and date it以標記筆圈出引流範圍並註明日期
— Explanation · 中文詳解 —
術後早期出現大量鮮紅滲血，首要之務是評估病人血液動力學狀態（生命徵象）並給予加壓止血，以防止失血性休克。單純加壓或標記雖然重要，但必須在確定生命徵象是否穩定後進行。通知醫師也是後續步驟，但需先完成基礎評估以提供正確資訊。
The priority is to assess the client's hemodynamic stability by applying direct pressure to control bleeding and checking vital signs for signs of hypovolemic shock. While notifying the surgeon is necessary, the nurse must first gather objective data regarding the client's current condition to provide an accurate report.
✦ 台美臨床差異
美台臨床皆視術後大量出血為緊急事件，但台灣護理師通常需同時備妥止血與輸血準備。