— 基本照護與舒適 · MEDIUM · MCQ —
護理師評估術後病人時，哪項發現需要立即介入？
Which assessment finding in a postoperative client requires immediate nursing intervention?
- APatient rating pain at 4/10病人自述疼痛指數為4/10
- BHypoactive bowel sounds腸鳴音減弱
- CBlood pressure of 120/80 mmHg血壓120/80 mmHg
- DUrine output of 20 mL/hour✓ 正解尿量20 mL/小時
— Explanation · 中文詳解 —
尿量是評估組織灌流與腎臟功能的敏感指標。每小時小於 30 mL 的尿量提示可能存在低血量、腎功能衰竭或休克前兆，必須立即評估病人的液體狀態並通知醫療團隊。腸鳴音減弱常見於術後腹部手術；4/10 疼痛需處理但非最優先；血壓正常。
Urine output is a sensitive indicator of tissue perfusion and renal function. Output less than 30 mL/hr suggests potential hypovolemia, renal failure, or impending shock—requiring immediate assessment of fluid status and notification of the team. Hypoactive bowel sounds are common after abdominal surgery; 4/10 pain needs treatment but is not the highest priority; blood pressure is normal.
✦ 台美臨床差異
台美皆視尿量為評估術後病人穩定度的關鍵，若低於標準需立即呈報醫師。