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一位成人個案在接受開放性腹主動脈瘤修補術後，正在麻醉後恢復室接受照護。請檢視連續記錄的臨床數據，判斷面對此變化趨勢的優先處置。

Trend

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Time	Data
1400	BP 128/76 mm Hg, HR 78/min, RR 14/min, SpO2 98% on 4 L/min, alert; drain has scant sanguineous output.BP 128/76 mm Hg, HR 78/min, RR 14/min, SpO2 98% on 4 L/min, 警覺；引流管有少量血性引流液。
1430	BP 110/68 mm Hg, HR 92/min, RR 18/min, restless; drain output is increasing.BP 110/68 mm Hg, HR 92/min, RR 18/min, 躁動；引流液量增加中。
1500	BP 92/58 mm Hg, HR 110/min, RR 22/min; urine output is 15 mL during the prior hour.BP 92/58 mm Hg, HR 110/min, RR 22/min；前一小時尿量為 15 mL。
1530	BP 82/50 mm Hg, HR 124/min, RR 26/min, pale and confused; 250 mL bright-red drain output accumulated in 30 minutes.BP 82/50 mm Hg, HR 124/min, RR 26/min, 蒼白且混亂；30分鐘內累積 250 mL 鮮紅色引流液。

Q1. How should the nurse interpret the overall trend?護理師應如何判讀整體趨勢？

Improving perfusion灌注改善 Stable postoperative recovery穩定的術後恢復 Rapid deterioration consistent with acute blood loss快速惡化，符合急性血液流失

Q2. What is the priority response?優先處置為何？

Increase oxygen and resume routine monitoring增加氧氣並恢復常規監測 Activate emergency surgical escalation and prepare resuscitation and source-control support啟動緊急外科升級並準備復甦與源頭控制支持 Give PRN opioid medication before reporting the findings在報告數據前先給予 PRN 鴉片類藥物

Q3. Which additional action best supports the response?哪項額外措施最能支持此處置？

Delay laboratory testing until the next scheduled round延後實驗室檢驗至下次排程巡房 Remove existing IV access to reduce bleeding移除現有靜脈通路以減少出血 Encourage oral fluids before notifying the team在通知團隊前鼓勵口服液體 Prepare ordered blood products and maintain large-bore access while the team evaluates the bleeding source準備醫囑血液製品並維持大管徑通路，同時讓團隊評估出血來源

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