一位腹部手術後第二天的病人，下列哪些發現顯示可能存在需要立即回報的併發症？（選所有適合的）
A nurse is caring for a client who is post-operative day 2 following an abdominal surgery. Which of the following findings would indicate a potential complication that requires immediate reporting? (Select all that apply.)
- AInability to pass flatus for 48 hours48小時內無法排氣
- BRedness and warmth around the incision site✓ 正解切口周圍紅腫發熱
- CPresence of sanguineous drainage on the dressing敷料上有血性滲出液
- DTemperature of 101.5°F (38.6°C)✓ 正解體溫 101.5°F (38.6°C)
- ESudden onset of dyspnea and tachycardia✓ 正解突發性呼吸困難與心跳過速
術後照護的核心在於識別早期併發症。腹部手術後，切口處紅腫熱（感染徵兆）、發燒（可能為傷口感染、尿路感染或肺部合併症）、以及突發性呼吸困難伴隨心跳過快（高度懷疑肺栓塞 Pulmonary Embolism, PE）均屬危急徵象，需立即通知醫師。術後腸蠕動恢復緩慢為常見現象，少量血水滲出在預期範圍內，故不需緊急回報。
Redness and warmth at the incision site suggest a surgical site infection, while fever may indicate infection or pulmonary complications. Sudden dyspnea and tachycardia are classic signs of a pulmonary embolism, a life-threatening emergency. These findings require immediate reporting, whereas absence of flatus and small amounts of drainage are expected postoperative occurrences.
美國臨床對於術後發燒的閾值通常設定較嚴格，超過 101.5°F (38.6°C) 常規會啟動感染評估流程（如血液培養、尿液檢查）。台灣臨床對術後發燒的容忍度有時較高，但 NCLEX 考試中，任何導致生命徵象改變的跡象均需優先處理。