— 降低風險 · MEDIUM · SATA —
護理師照顧一位使用持續性傷口沖洗系統的病人。下列哪些發現需要立即介入？（選所有適合的）
A nurse is caring for a client with a continuous wound irrigation system. Which findings require immediate intervention? (Select all that apply.)
- AThe drainage tubing is kinked✓ 正解引流管路扭結
- BThe irrigation fluid has turned cloudy✓ 正解沖洗液變混濁
- CThe surrounding skin is macerated✓ 正解周圍皮膚浸潤
- DThe outflow rate is equal to the infusion rate流出率等於輸入率
- EThe client reports a mild itching sensation病人報告輕微搔癢感
— Explanation · 中文詳解 —
傷口沖洗系統若引流管扭曲（A）會導致液體積聚壓力上升；沖洗液混濁（B）是感染徵兆；周圍皮膚浸潤（C）顯示密封不佳或過度潮濕，皆須立即處理。D 是正常現象（出入平衡）；E 若非嚴重過敏，通常可持續觀察。
Immediate intervention is required for kinked drainage tubing, which prevents proper outflow, and cloudy irrigation fluid, which indicates potential infection. Macerated surrounding skin also necessitates prompt care to prevent tissue breakdown and secondary infection.
✦ 台美臨床差異
美國護理師常具備傷口護理師專科認證，處理傷口系統較具自主權；台灣多在醫師指導下進行傷口處置計畫。