— 降低風險 · EASY · MCQ —
護理師照護一位剛從恢復室返回病房的腹部手術病人。下列哪項發現需要立即的護理介入？
A nurse is caring for a client who has just returned from the post-anesthesia care unit following an abdominal surgery. Which finding requires immediate nursing intervention?
- ARespiratory rate 8 breaths/min✓ 正解呼吸频率为每分钟8次
- BDrowsiness when stimulated受刺激时嗜睡
- CBlood pressure 105/65 mmHg血压 105/65 mmHg
- DPulse 85 bpm脉搏 85 bpm
— Explanation · 中文詳解 —
術後恢復期的病人，呼吸功能監測是護理的優先順序（Priority）。呼吸頻率每分鐘 8 次屬於嚴重呼吸抑制（Respiratory depression），這通常是鴉片類止痛藥（Opioids）或麻醉藥殘留的毒性反應。二氧化碳滯留會導致酸中毒及缺氧，若不立即介入，可能進展為呼吸停止，這是危及生命的緊急情況，必須優先處理。
A respiratory rate of 8 breaths per minute indicates significant respiratory depression, likely due to residual anesthesia or opioid analgesics, which is a life-threatening emergency requiring immediate intervention to prevent hypoxia and respiratory arrest.