護理長檢視單位病人名單。哪些個案發現需要立即追蹤?請標示護理師應優先處理的發現。 | MyMerci
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護理長檢視單位病人名單。哪些個案發現需要立即追蹤?請標示護理師應優先處理的發現。

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Client個案Current finding目前發現
Client 2個案 2 The new colostomy is pink and moist with a small amount of serosanguineous drainage.新造口呈粉紅色且濕潤,有少量漿液血性引流液。
Client 1個案 1 Four hours after thyroid surgery, a new high-pitched sound is heard during inspiration.甲狀腺手術後四小時,吸氣時聽到新的高頻音。
Client 4個案 4 Oxygen saturation is 90% on the prescribed oxygen, within the documented target range.在醫囑氧氣下血氧飽和度為 90%,在記錄的目標範圍內。
Client 3個案 3 The right arm suddenly drifts downward and speech becomes slurred during conversation.談話中右臂突然下垂且言語變得含糊。
Client 5個案 5 Bruising remains localized around the repaired hip and has not enlarged since morning.修補後的髖部周圍瘀傷仍局限,且自早上以來未擴大。
Client 7個案 7 Abdominal pain decreased from 7 to 3 after the prescribed analgesic was given.給予醫囑止痛劑後腹痛由 7 分降至 3 分。
Client 6個案 6 No thrill is felt over the arteriovenous fistula before the scheduled dialysis treatment.預定透析治療前,動靜脈瘻管處未觸及震顫。
Client 9個案 9 Urine output is 550 mL after intravenous furosemide, and breathing is less labored.靜脈注射 furosemide 後尿量為 550 mL,且呼吸較不費力。
Client 8個案 8 A client with sickle cell disease has a temperature of 38.6 °C and a new cough.鐮刀型貧血個案體溫 38.6 °C 且有新咳嗽。
解析
新出現的呼吸道雜音、突然的局部神經學變化、透析通路血流消失,以及鐮刀型貧血合併發燒,都可能快速威脅生命或治療通路。應優先處理急性惡化,而非預期中的恢復期發現。
相同主題的下一題A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000
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