# 檢視手術部位感染趨勢。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395956&lang=zh-tw  
> language: zh-TW  
> subject: Standard/Transmission-Based Precautions/Surgical Asepsis  
> category: SIPC

## 題目

檢視手術部位感染趨勢。

| Time | Data |
| --- | --- |
| Post-op day 1 | 傷口邊緣對齊，體溫 37.1°C，疼痛 3/10 |
| Post-op day 4 | 切口疼痛加劇，發紅範圍延伸 3 公分，體溫 38.4°C |
| Post-op day 5 | 膿性引流液，白血球計數 15,500/mm³，傷口邊緣分離 |

Q1. 此情況暗示何種併發症？

手術部位感染，有傷口裂開風險
僅為正常癒合
預期中的瘀傷
過敏性鼻炎

Q2. 下列何項護理處置最為適當？

通知醫師，並依醫囑使用無菌傷口護理
以徒手使用非無菌敷料
鼓勵搔抓切口
延遲至追蹤時再通報

## 解析

疼痛加劇、發紅範圍擴大、發燒、膿性引流液、白血球增多及傷口邊緣分離，顯示有手術部位感染及傷口裂開的風險。無菌照護及立即通知醫療提供者為優先事項。

## 深入解析

臨床判斷
趨勢題型要求你察覺隨時間變化的項目，以及哪一項變化會造成最高風險。將最強烈的線索模式與手術部位感染趨勢最安全的護理優先順序連結起來。

記憶提示
趨勢、線索嚴重度及立即風險，決定了常規工作前的優先順序。

KR vs US
NCLEX NGN 題目獎勵運用完整個案圖像的臨床判斷，而非單一孤立的線索。

## 臨床情境

臨床實務指引
針對手術部位感染趨勢，在選擇優先因應措施前，應將新發現與基準狀態、醫囑資料及預期併發症進行比較。

注意
當呼吸道、呼吸、循環、神經學狀態或安全狀況惡化時，切勿延遲緊急穩定處置或通報。

## 重要概念

- **手術部位感染** — 涉及切口或手術區域的感染。
- **傷口裂開** — 傷口邊緣部分或完全分離。
- **膿性引流液** — 含有膿液的濃稠引流物。

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