護理師正在監測一位 2 小時前接受過腰椎穿刺（Lumbar Puncture）的病人。下列哪項發現需要立即介入以降低潛在併發症的風險？
The nurse is monitoring a client who underwent a lumbar puncture 2 hours ago. Which finding requires immediate intervention to reduce the risk of potential complications?
- AClear fluid saturating the dressing at the puncture site✓ 正解穿刺部位敷料被清澈液體浸透
- BDifficulty voiding since the procedure術後排尿困難
- CClient report of a headache that worsens when sitting up病人主訴坐起時頭痛加劇
- DPain at the needle insertion site rated 3/10針頭插入部位疼痛評分為 3/10
腰椎穿刺後最嚴重的結構性併發症是腦脊髓液（CSF）滲漏。如果敷料被清澈液體浸透（A），代表穿刺孔未閉合，CSF 持續外流，這會導致顱內壓下降，增加感染（腦膜炎）風險，甚至誘發腦疝脫（Herniation）。護理師必須立即通知醫師重新加壓止血或進行 Blood Patch。雖然「姿勢性頭痛」（C）是 LP 後常見的併發症，原因是 CSF 減少，但通常透過平躺和補液可緩解，且其緊急程度不如「持續活動性滲漏」。解尿困難（B）可能與術後平躺限制有關，需評估但非首要；局部疼痛（D）是預期中的，不具危險性。此題測驗護理師對「硬膜下滲漏」這一嚴重風險的辨識能力。
The most experienced nurse should care for clients with unstable conditions, such as those post-myocardial infarction, as they require frequent assessment and critical decision-making. Clients experiencing complex alcohol withdrawal or requiring titration of vasopressors also need advanced monitoring and physiological expertise. Routine tasks like insulin education or caring for uncomplicated fractures can be safely assigned to less experienced nurses.
美國護理實務強調術後平躺 4-6 小時並嚴密觀察敷料；台灣臨床上，LP 後平躺時間要求通常較長（6-8 小時），且護理師若發現滲漏，通常會直接由醫師在床邊進行再次壓迫止血，流程高度依賴醫師判斷。