— 降低風險 · MEDIUM · MCQ —
護理師正在照顧一位腹部手術後第二天的病人。病人抱怨腹部脹氣且無法排氣。護理師應首先實施下列哪項措施？
A nurse is caring for a client who is postoperative day 2 after abdominal surgery. The client reports abdominal distension and inability to pass flatus. Which intervention should the nurse implement first?
- AInsert a nasogastric tube插入鼻胃管
- BEncourage ambulation✓ 正解鼓勵下床活動
- CNotify the surgeon通知外科醫師
- DAdminister a prescribed laxative給予處方緩瀉劑
— Explanation · 中文詳解 —
術後腹脹與無法排氣通常是由麻醉藥物、手術刺激導致的腸蠕動減緩（麻痺性腸阻塞，Paralytic ileus）。在執行侵入性介入措施前，護理師應優先採取非藥物、非侵入性的護理措施以刺激蠕動。早期下床活動（Ambulation）能透過身體活動增加腸道機械性蠕動，是促進排氣、預防術後腸阻塞最有效且符合成本效益的優先護理處置。
During illness, stress hormones and hepatic glucose release can elevate blood sugar, making frequent monitoring (every 3-4 hours) and ketone testing (if glucose >240 mg/dL) essential to prevent diabetic ketoacidosis. Clients must never stop insulin, maintain hydration, and contact their provider if vomiting persists to avoid complications from inability to tolerate oral intake.