— 降低風險 · HARD · MCQ —
一位疑似敗血症的病人，護理師評估液體復甦成效時，下列哪項指標最為優先？
A client presents with signs of sepsis. Which nursing assessment is the highest priority when evaluating the effectiveness of fluid resuscitation?
- AHourly urine output✓ 正解每小時尿量
- BSkin turgor皮膚彈性
- CHeart rate心率
- DBlood pressure血壓
— Explanation · 中文詳解 —
敗血症病人在液體復甦（Fluid Resuscitation）期間，單純的血壓或心率容易受疼痛、藥物或壓力影響。每小時尿量（Hourly urine output）是反映組織灌流（Tissue perfusion）與腎功能最可靠的指標，能直接量化腎臟灌注情況，是評估輸液反應的最佳數據。
During fluid resuscitation in a client with sepsis, blood pressure or heart rate alone may be easily influenced by pain, medications, or stress. Hourly urine output is the most reliable indicator reflecting tissue perfusion and renal function, directly quantifying renal perfusion, and is the best parameter for evaluating the response to fluid therapy.
✦ 台美臨床差異
美國 ICU 常規會置放 Foley 以監測小時尿量；台灣臨床亦同，但在資源分配上可能偶有延遲。