— 降低風險 · EASY · MCQ —
一位病人剛從手術室返回病房接受腹部手術，下列哪項評估發現護理師應優先處理？
A nurse is caring for a client who has just returned from the operating room following an abdominal surgery. Which assessment finding should the nurse prioritize?
- AHeart rate of 95 bpm心率95次/分。
- BAbsent bowel sounds腸鳴音消失。
- CPain score of 6 out of 10疼痛評分6分（滿分10分）。
- DOxygen saturation of 88%✓ 正解血氧飽和度88%。
— Explanation · 中文詳解 —
術後護理首重呼吸道與氧合狀況（ABC原則）。SpO2 88% 低於正常範圍，代表病人存在缺氧風險，必須立即採取介入。腸鳴音缺失是術後常見現象，疼痛與心跳輕微升高通常在術後觀察範圍內，皆非危及生命的立即威脅。
An oxygen saturation of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate tissue perfusion and prevent respiratory failure. While absent bowel sounds and mild tachycardia are common postoperatively, airway and breathing take precedence over pain management.
✦ 台美臨床差異
美台護理界對於術後 SpO2 警戒線定義相似，但美國更強調早期離床與肺部復健，台灣則較重視止痛藥物的給藥間隔。