# 腹部手術後 2 小時，個案敷料已滲濕飽和，心率 126 次/分，血壓 88/50 mm Hg。護理師第一步應做什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

腹部手術後 2 小時，個案敷料已滲濕飽和，心率 126 次/分，血壓 88/50 mm Hg。護理師第一步應做什麼？

## 選項

1. 對切口施加穩定壓力並通知外科團隊。 **✔ 正確答案**
2. 記錄引流量並 1 小時後再評估。
3. 移除敷料並讓切口暴露於空氣。
4. 鼓勵個案下床走動以改善循環。

**正確答案: 1**

## 解析

術後敷料飽和合併心搏過速與低血壓，提示活動性出血與可能休克。護理師應依政策加壓、維持安全並立即通知外科團隊。延後再評估、暴露切口或走動可能加重出血與不穩定。

## 深入解析

臨床判斷
將引流與生命徵象變化連結到出血風險並立即行動。

記憶重點
出血加低血壓：立即加壓並通知。

## 臨床情境

實務指引
術後出血評估包括敷料飽和、生命徵象、意識、尿量，以及 hemoglobin 和 hematocrit 等檢驗趨勢。

注意
不要因一般術後疼痛而忽略出血徵象。

## 重要概念

- **術後出血** — 手術後出血，可能表現為敷料飽和、心搏過速、低血壓、蒼白或 hemoglobin 下降。
- **低血容量性休克** — 因出血或體液流失造成循環量下降的休克。
- **CBC** — 全血球計數，包含 hemoglobin 與 hematocrit，可用於出血評估。

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