# 一位個案因小腿傷口感染入院。護理師應立即通報哪項發現？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498891&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: PA ## 題目 一位個案因小腿傷口感染入院。護理師應立即通報哪項發現？ ## 選項 1. 現有敷料上有少量漿液性滲出液 2. 口腔溫度 37.7°C，補充液體後下降 3. 快速擴散的腫脹，伴隨超出發紅區域的劇烈疼痛 **✔ 正確答案** 4. 白血球計數 11,800/mm3，重複檢測無其他變化 **正確答案: 3** ## 解析 快速進展和超出可見皮膚變化的疼痛，是壞死性筋膜炎的警訊。此感染可迅速破壞組織並導致敗血症，需要緊急外科和抗微生物評估。 ## 深入解析 快速解答 將快速擴散的腫脹和超出可見發紅的疼痛，提升為外科急症處理。 為什麼這是正確的 壞死性感染可能沿著深層筋膜進展，速度比表面發現更快。不成比例的劇烈疼痛和快速擴大的水腫，表示有侵襲性的組織損傷，因此延遲外科評估會顯著增加罹病率和死亡率。 簡單比喻或心智圖像 感染可能在皮膚下擴散，就像火在牆後蔓延，在火焰明顯之前就已發生。這個比喻說明了隱藏的進展，但無法確認診斷或鑑定病原體。 記憶掛鉤 疼痛超出外觀加上快速擴散，意味著壞死性急症。 NCLEX 決策規則 在軟組織感染中，優先處理快速進展、不成比例的疼痛、全身毒性、水泡或皮膚壞死。這些發現比少量滲液、低度體溫變化或輕度單獨白血球增多更為重要。 為什麼其他選項是錯的 少量漿液性滲液並未顯示快速進展的深層組織損傷。此體溫趨勢若無全身性惡化，較不緊急。快速擴散伴隨不成比例的疼痛，需要立即升級處理。輕度單獨白血球增多，特異性不如臨床危險訊號。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]Clinical Guidance for Type II Necrotizing FasciitisU.S. Centers for Disease Control and Prevention ## 相同主題題目 - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498891&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498891&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498891&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498891&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498891&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_