— 降低風險 · MEDIUM · MCQ —
護理師評估一位下肢使用外固定器的病人，哪項發現應優先回報醫師？
A nurse is monitoring a client with an external fixation device on the lower leg. Which finding should the nurse prioritize reporting to the provider?
- AClear drainage at the pin sites釘道處有清澈滲出液
- BMild discomfort when moving toes移動腳趾時有輕微不適
- CSmall amounts of serosanguineous crusting少量漿液血性結痂
- DIncreased pain not relieved by medication✓ 正解疼痛加劇且藥物無法緩解
— Explanation · 中文詳解 —
外固定器（External fixation）術後，護理師的監測重點在於神經血管狀態（Neurovascular status）。若病人出現藥物無法緩解的疼痛，且伴隨其他腔室症候群（Compartment syndrome）徵兆（如蒼白、麻木、脈搏減弱），代表局部壓力過大造成組織缺血。這屬於極度緊急的醫療狀況，必須立即回報以進行減壓處理，否則恐導致肢體壞死。
Increased pain not relieved by medication is a priority finding as it may indicate neurovascular compromise or compartment syndrome. This requires immediate reporting to prevent tissue ischemia and potential limb necrosis, unlike mild discomfort or expected drainage which are less urgent.