— 降低風險 · EASY · MCQ —
護理師評估一位腸切除術後 24 小時的病人，發現病人已有 4 小時未聽到腸鳴音。護理師應採取何種行動？
A nurse is assessing a client who is 24 hours postoperative following a bowel resection. The nurse notes the client has had no bowel sounds for 4 hours. Which action should the nurse take?
- ADocument the findings as an expected occurrence✓ 正解將發現記錄為預期發生的情況
- BIncrease the IV fluid infusion rate增加靜脈輸液速率
- CAmbulate the client in the hallway協助病人至走廊散步
- DNotify the surgeon immediately regarding the ileus立即通知醫師關於腸阻塞的情況
— Explanation · 中文詳解 —
腸切除術後發生暫時性腸麻痺（Postoperative ileus）是腹部手術後的預期生理反應。由於麻醉藥物、手術干預及疼痛，腸道蠕動會暫時停止，通常在術後 24 至 48 小時內恢復。護理師需評估是否有腸阻塞併發症，如嘔吐、腹脹或腹痛，若無這些症狀，僅發現腸鳴音減弱或消失，屬於正常恢復期表現，記錄即可。
Postoperative ileus is an expected physiological response following abdominal surgery, typically resolving within 24 to 48 hours. In the absence of complications such as vomiting or severe distension, documenting this finding is appropriate without immediate notification.