一位全層燒傷病人正處於緊急復甦期（emergent phase），下列哪項發現需優先回報醫師？
A nurse is caring for a client who has sustained a full-thickness burn. During the emergent phase, which finding is the priority to report to the provider?
- ASerum potassium level of 4.2 mEq/L血清鉀離子濃度 4.2 mEq/L
- BHeart rate of 95 beats/min心率 95 次/分
- CUrine output of 20 mL/hr✓ 正解尿量 20 mL/小時
- DBlood pressure of 105/65 mmHg血壓 105/65 mmHg
燒傷後緊急期最大的風險為循環衰竭與低血容積休克。成人燒傷復甦期的目標尿量應維持在 0.5-1.0 mL/kg/hr，約 30-50 mL/hr。尿量 20 mL/hr 代表腎臟灌流不足，顯示補液不足或休克加劇。BP 105/65 與 HR 95 屬於邊緣正常範圍，鉀離子 4.2 屬於正常值。
During the emergent phase after a burn, the greatest risks are circulatory failure and hypovolemic shock. The target urine output during fluid resuscitation in an adult burn client is 0.5–1.0 mL/kg/hr, approximately 30–50 mL/hr. A urine output of 20 mL/hr indicates inadequate renal perfusion and reflects insufficient fluid resuscitation or worsening shock. A BP of 105/65 and HR of 95 are within borderline-normal range, and potassium of 4.2 is within normal limits.
美國護理師常依 Parkland 公式自主調整輸液速度，台灣醫師權限較嚴，輸液調整需依醫囑頻繁校正。