# 一位腹部手術後2小時的個案，心跳122次/分，血壓86/50 mm Hg，皮膚濕冷，且腹部敷料引流液增加。護理師應懷疑何種併發症？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397166&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

一位腹部手術後2小時的個案，心跳122次/分，血壓86/50 mm Hg，皮膚濕冷，且腹部敷料引流液增加。護理師應懷疑何種併發症？

## 選項

1. 尿滯留。
2. 麻痺性腸阻塞。
3. 正常的術後疼痛反應。
4. 出血。 **✔ 正確答案**

**正確答案: 4**

## 解析

術後出現心搏過速、低血壓、皮膚濕冷及引流液增加，是可能出血及休克的線索。尿滯留和腸阻塞無法解釋出血及灌流不足的線索。單純疼痛也無法解釋完整的模式。

## 深入解析

臨床判斷
利用個案線索、時間點、檢驗數據及安全風險，選擇最符合術後出血線索的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
針對術後出血線索，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **出血** — 過度失血，可能減少循環血量。
- **休克** — 組織灌流不足，可能導致器官功能障礙。
- **術後引流液** — 來自手術部位的液體，可能代表預期的癒合或併發症。

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