一名低血容性休克病人入院，護理師在初步檢查中應優先評估哪項發現？
A client is admitted with hypovolemic shock. Which assessment finding should the nurse prioritize during the initial examination?
- ABowel sounds in all four quadrants四個象限均有腸音
- BSerum potassium level of 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
- CPresence of peripheral edema存在周邊水腫
- DCapillary refill time of 5 seconds✓ 正解毛細血管再充盈時間為 5 秒
低血容性休克發生時，組織灌流不良是核心問題。微血管填充時間（CRT）是大於 3 秒即顯示周邊循環灌流不足，能直接反映血流動力學狀態，是評估休克嚴重度的重要生理指標。其他選項如鉀離子屬於生化檢查，腸音及水腫則屬於次要或慢性評估，優先級低於急性循環指標。
In hypovolemic shock, the core problem is impaired tissue perfusion. A capillary refill time (CRT) greater than 3 seconds indicates inadequate peripheral perfusion and directly reflects hemodynamic status, making it an important physiologic indicator of shock severity. The other options, such as a potassium level (a laboratory test), bowel sounds, and edema, are secondary or more chronic findings with lower priority than acute circulatory indicators.
美國護理師在 triage 及急診評估時即會執行完整的循環與灌流檢查；台灣護理師執行頻率依單位而異，急診單位較為落實。