— 降低風險 · MEDIUM · MCQ —
一位術後帶有持續性傷口引流管的病人，哪項評估發現需要立即通知外科醫師？
A nurse is caring for a client with a continuous wound suction drain. Which assessment finding requires immediate notification to the surgeon?
- ASudden increase in bright red drainage✓ 正解鮮紅色引流液突然增加
- BPresence of a small amount of dark red blood存在少量暗紅色血液
- CSmall amount of serosanguineous drainage少量漿液血性引流液
- DDischarge appearing cloudy and odorless引流液呈渾濁且無味
— Explanation · 中文詳解 —
術後引流液若出現突然的大量鮮紅色血液，暗示可能有血管斷裂或出血點未止，屬於緊急臨床警訊。Serosanguineous（漿液血性）或少許暗紅色血液（陳舊血）通常在預期範圍內。混濁無味可能為正常現象或初期發炎，嚴重度較急性出血低。
A sudden increase in bright red drainage suggests active hemorrhage, such as a ruptured vessel, requiring immediate surgical evaluation. While small amounts of dark red blood or serosanguineous drainage are often expected postoperatively, frank bleeding is an emergency.
✦ 台美臨床差異
美國護理師對出血量的定義有明確的量化標準（例如 100ml/hr），台灣則多仰賴護理師的臨床判斷力回報。