— 降低風險 · EASY · MCQ —
護理師照護一位術後放置 Jackson-Pratt 引流管的病人，哪項評估結果顯示有併發症的可能？
A nurse is caring for a postoperative client with a Jackson-Pratt drain. Which assessment finding indicates a potential complication?
- AThe bulb remains collapsed引流球保持塌陷狀態
- BDrainage fluid is bright red✓ 正解引流液呈鮮紅色
- CDrainage color changes from red to serosanguineous引流液顏色由紅色變為血性漿液
- DDrainage volume is 30 mL in 8 hours8小時內引流液量為30 mL
— Explanation · 中文詳解 —
術後引流液應隨時間由鮮紅色轉為漿液血性（serosanguineous）再轉為漿液性（serous）。若引流液維持鮮紅色，暗示存在活動性出血，需立即評估生命徵象並通知外科醫師。D 選項屬正常範疇，A 選項表示真空吸力正常，無須擔心。
Postoperative drainage should transition from bright red to serosanguineous and then to serous as healing progresses. Persistent bright red drainage indicates active bleeding, which is a potential complication requiring immediate assessment and notification of the provider.
✦ 台美臨床差異
台美對引流管管理標準相似，但美國護理師常需負責教導病人居家引流管理，台灣則多於住院期間由護理師操作。