— 降低風險 · MEDIUM · MCQ —
護理師正在照顧一位接受全髖關節置換術後第一天的病人。病人突然抱怨嚴重的腿肚疼痛和腫脹。護理師應優先採取的行動是什麼？
A nurse is caring for a client who is post-operative day 1 after a total hip replacement. The client reports sudden severe calf pain and swelling. What is the nurse's priority action?
- ANotify the surgeon immediately✓ 正解立即通知醫師
- BAdminister a prescribed analgesic給予處方止痛藥
- CElevate the affected leg抬高患肢
- DApply a warm compress to the calf在小腿處施加溫熱敷
— Explanation · 中文詳解 —
全髖關節置換術（Total Hip Replacement）術後病人處於極高血栓風險狀態。突發性的小腿疼痛、紅腫、壓痛是深層靜脈血栓（DVT）的典型臨床表現。DVT 若脫落可能引發致命的肺栓塞（PE）。護理師必須立即通知醫師進行診斷（如 Doppler 超音波）與抗凝血處置，不可自行處理或按摩患部。
Sudden calf pain and swelling after hip replacement surgery are classic signs of deep vein thrombosis (DVT), which carries a risk of fatal pulmonary embolism. The nurse must notify the surgeon immediately for diagnostic confirmation and anticoagulant therapy rather than attempting to manage the pain or swelling independently.