— 照護管理 · MEDIUM · MCQ —
一位 45 歲女性病人，膽囊切除術後第二天。下列哪項評估發現應立即回報醫師？
A nurse is caring for a 45-year-old female client who is post-operative day 2 following an open cholecystectomy. Which assessment finding should the nurse report to the provider?
- AClay-colored stools✓ 正解陶土色糞便
- BReports of shoulder pain when moving活動時報告肩膀疼痛
- CIncisional pain rated as 3/10切口疼痛評分為 3/10
- DAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
— Explanation · 中文詳解 —
膽囊切除術後出現灰白色糞便（Clay-colored stools），代表膽道阻塞或膽汁無法進入腸道，這是一個嚴重的術後併發症跡象。其餘選項皆為術後常見的預期性表現（腸蠕動暫時消失、預期疼痛、CO2 殘留引起的肩痛）。
Clay-colored stools indicate bile duct obstruction or lack of bile entering the intestine, which is a serious postoperative complication requiring immediate provider notification. Other options represent expected postoperative findings such as manageable pain, transient absence of bowel sounds, or referred shoulder pain from surgical gas.
✦ 台美臨床差異
此類臨床發現的判斷標準在全球護理界皆一致，對膽管阻塞的警覺性是術後照顧的核心指標。