— 照護管理 · MEDIUM · MCQ —
一位護理師正在接收入院一位有嚴重脫水的病人。哪項評估發現需要立即介入？
A nurse is admitting a client with severe dehydration. Which assessment finding requires immediate intervention?
- ADecreased skin turgor.皮膚張力降低。
- BBlood pressure of 90/50 mmHg.✓ 正解血壓 90/50 mmHg。
- CUrine output of 20 mL in the last hour.過去一小時的尿量為 20 mL。
- DDry mucous membranes.黏膜乾燥。
— Explanation · 中文詳解 —
血壓 90/50 mmHg 代表病人的循環系統已無法維持足夠的灌流壓，這在嚴重脫水病人身上是「低血容量性休克」（Hypovolemic shock）的徵兆。這屬於危及生命的緊急情況，必須立即通知醫師，給予快速靜脈輸液（Fluid resuscitation）以擴充循環容積，否則將導致器官灌流不足而衰竭。
A blood pressure of 90/50 mmHg indicates that the client's circulatory system can no longer maintain adequate perfusion pressure; in a severely dehydrated client, this is a sign of hypovolemic shock. It represents a life-threatening emergency, and the physician must be notified immediately to initiate rapid IV fluid resuscitation to expand circulating volume; otherwise organ hypoperfusion and failure will occur.