— 照護管理 · HARD · MCQ —
一位嚴重內出血病人。哪項臨床表現代表需優先處置？
A nurse is managing a client with severe internal hemorrhage. Which finding indicates the priority need for action?
- AHemoglobin level of 9.2 g/dL血色素 9.2 g/dL
- BBlood pressure of 110/70 mmHg血壓 110/70 mmHg
- CHeart rate of 95 beats per minute每分鐘 95 次的心率
- DUrine output of 20 mL/hour✓ 正解每小時 20 mL 的尿量
— Explanation · 中文詳解 —
尿量每小時少於 30 mL 顯示腎臟灌流不足，是休克代償機制失靈或灌流嚴重不足的重要警訊。相較於輕度貧血數值或尚在代償範圍內的血壓脈搏，少尿代表器官灌流已受損，需立即補充液體或處理出血源。ABC 原則中，循環灌流（B）的改善是關鍵。
A urine output below 30 mL/hour indicates inadequate renal perfusion—an important warning that compensatory mechanisms may be failing or perfusion is critically reduced. Compared with mild anemia, still-compensated blood pressure, and pulse, oliguria reflects organ perfusion compromise requiring immediate fluid resuscitation or control of bleeding. Improving circulation (the C in ABC) is the key.
✦ 台美臨床差異
兩地護理原則一致，均以每小時尿量作為監測循環灌流的臨床金標準。