— 生理適應 · EASY · MCQ —
護理師照護一位嚴重脫水病人。下列哪項發現顯示液體容積補充已成功？
A nurse is caring for a client with severe dehydration. Which finding indicates successful fluid volume replacement?
- ARespiratory rate of 28 breaths per minute呼吸頻率為每分鐘28次
- BSerum potassium level of 5.8 mEq/L血清鉀濃度為5.8 mEq/L
- CBlood pressure increase from 80/50 to 110/70 mmHg✓ 正解血壓從80/50上升至110/70 mmHg
- DUrine output of 10 mL/hr尿量為每小時10 mL
— Explanation · 中文詳解 —
評估液體回補成功，主要指標為生命徵象穩定。血壓回升顯示血管內容積改善，組織灌流恢復。尿量小於 30 mL/hr 指示腎臟灌流不足，鉀離子過高顯示腎功能異常或細胞崩解，呼吸過快可能是代償性酸中毒或肺部併發症，皆不表復原。
When evaluating successful fluid resuscitation, the main indicator is stabilization of vital signs. A rising blood pressure reflects improvement in intravascular volume and restoration of tissue perfusion. Urine output less than 30 mL/hr indicates insufficient renal perfusion, an elevated potassium level suggests abnormal renal function or cellular breakdown, and tachypnea may indicate compensatory acidosis or pulmonary complications; none of these represent recovery.
✦ 台美臨床差異
美台臨床皆視尿量為核心指標，但美國 RN 評估後可直接調整 IV 速度；台灣多需根據醫囑範圍調整。