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降低風險 · EASY · MCQ

護理師護理一名使用 Jackson-Pratt 引流管的術後病人,下列哪項評估發現需立即報告外科醫師?

A nurse is caring for a postoperative client with a Jackson-Pratt drain. Which assessment finding should the nurse report to the surgeon immediately?

  • AThe bulb is compressed and collapsed
    引流球體處於壓縮且塌陷狀態
  • BDrainage changing from serosanguineous to bright red blood✓ 正解
    引流液由血清血性轉變為鮮紅色血液
  • CSmall amount of dark red drainage on the dressing
    敷料上有少量暗紅色引流液
  • DClear, serous fluid drainage
    清澈的漿液性引流液
Explanation · 中文詳解

Jackson-Pratt (JP) 引流管是術後常見的閉合式引流系統。評估引流液性質是監測術後恢復的核心指標。正常引流液會隨著時間由血性(sanguineous)轉為漿血性(serosanguineous),最後變為漿液性(serous)。若引流液突然轉為鮮紅色,暗示傷口內部可能有活動性出血(active hemorrhage),這屬於緊急狀況,必須立即報告外科醫師評估是否需要介入。其他選項均為預期的術後表現或正確的設備維護方式。

A sudden change in Jackson-Pratt drain output from serosanguineous to bright red blood suggests active hemorrhage, which is a surgical emergency requiring immediate physician notification. Normal postoperative drainage typically progresses from bloody to serosanguineous and finally to serous. A compressed bulb indicates proper suction function, while small amounts of dark red drainage or clear serous fluid are expected findings during recovery.

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