— 降低風險 · HARD · MCQ —
下列何者為術後病人需立即處理的評估發現？
Which of the following findings in a post-operative client requires immediate intervention by the nurse?
- ASerosanguineous drainage on the dressing敷料上有漿液血性引流物
- BUrine output of 25 mL over the past hour過去一小時的尿液輸出量為 25 mL
- CSudden onset of dyspnea and tachycardia✓ 正解突發性呼吸困難與心搏過速
- DReported pain level of 6 on a scale of 0-10在 0-10 的量表中報告的疼痛等級為 6
— Explanation · 中文詳解 —
術後突發呼吸困難（dyspnea）伴隨心跳過速（tachycardia）是肺栓塞（PE）的警訊，屬危及生命的緊急狀況，需立即通知醫師並給予氧氣與監測生命徵象。A 為正常引流；B 需介入但非危及生命；B 雖偏低但需先判斷是否為脫水或腎灌流問題，緊急度次於呼吸循環衰竭。
Sudden onset of dyspnea and tachycardia requires immediate intervention as these are classic signs of a potentially fatal pulmonary embolism. While serosanguineous drainage is expected and low urine output or moderate pain require monitoring, respiratory compromise takes highest priority.
✦ 台美臨床差異
美國術後快速反應小組（RRT）機制較成熟，台灣則多依賴護理師判斷後呼叫學長姐或值班醫師。