# 一位病人有新的結腸造口。護理師應立即報告哪項造口發現？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397295&lang=zh-tw  
> language: zh-TW  
> subject: Mobility/Immobility  
> category: BCC

## 題目

一位病人有新的結腸造口。護理師應立即報告哪項造口發現？

## 選項

1. 濕潤的粉紅色組織。
2. 第一天有輕微水腫。
3. 暗沉的紫藍色組織。 **✔ 正確答案**
4. 切口周圍輕微壓痛。

**正確答案: 3**

## 解析

健康的造口應濕潤且呈粉紅色至紅色。暗沉的紫藍色可能表示灌流受損，應立即報告。術後早期輕微水腫是可預期的，但顏色改變是優先事項。

## 深入解析

臨床判斷
利用病人線索、時間點、檢驗數據及安全風險，選擇最符合新結腸造口評估的回應。

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，而非單獨的回憶。

## 臨床情境

臨床實務指引
對於新結腸造口評估，將完整的線索模式與病人當前的穩定性、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

- **結腸造口術** — 一種從結腸到腹壁的手術開口。
- **造口** — 腹部上可見的造口開口。
- **灌流** — 維持組織健康所需的血流。

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