— 降低風險 · HARD · MCQ —
護理師評估一位腹部手術後的病人有無內出血徵象。下列哪項發現是最早期的指標？
A nurse is evaluating a client for signs of internal bleeding following an abdominal surgery. Which finding is the earliest indicator?
- ACool and clammy skin皮膚冰冷且濕冷
- BDecreased urine output尿液排出量減少
- CIncreased pulse rate✓ 正解脈搏速率增加
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
內出血發生時，身體會啟動代償機制以維持血壓。交感神經興奮導致心跳代償性增加（心搏過速）通常發生在血壓下降之前。血壓下降代表代償功能衰竭，屬於較晚期的徵象。皮膚濕冷與尿量減少亦為組織灌流不足的表現，發生時間晚於心跳加快。密切監測生命徵象趨勢是發現早期出血的關鍵。
Tachycardia is the earliest indicator of internal bleeding as the body compensates for blood loss to maintain cardiac output. Signs such as cool, clammy skin, decreased urine output, and hypotension occur later when compensatory mechanisms begin to fail. Monitoring heart rate trends is crucial for early detection of hemorrhage.
✦ 台美臨床差異
台美皆強調生命徵象的趨勢分析，而非單一數值，對於術後出血監測的照護準則相當一致。