— 基本照護與舒適 · HARD · MCQ —
護理師評估病人的體液狀態，下列何者是成人體液量最可靠的觀察指標？
A nurse is assessing a client's fluid status. Which finding is the most reliable indicator of fluid volume status in an adult client?
- AMucous membrane hydration黏膜水合狀況
- BDaily weight changes✓ 正解每日體重變化
- CSkin turgor assessment皮膚張力評估
- DPresence of peripheral edema周邊水腫的存在
— Explanation · 中文詳解 —
每日體重測量是評估體液平衡最敏感、準確的數據。1 kg 體重改變約等於 1 L 液體進出。其他指標如水腫（受重力影響，出現時已滯留過多液體）、皮膚張力（受年齡影響）與黏膜乾燥（受呼吸、環境影響）均不如體重測量客觀精準。
Daily weight is the most sensitive and accurate indicator of fluid balance. A 1 kg change in body weight corresponds to roughly 1 L of fluid gained or lost. Other indicators such as edema (gravity-dependent and appears only after significant retention), skin turgor (affected by age), and dry mucous membranes (affected by breathing and environment) are less objective and precise than weight measurement.
✦ 台美臨床差異
美國護理紀錄中對 Daily Weight 的趨勢分析要求嚴格；台灣臨床上常因忙碌而未落實相同條件（如未空腹、衣物重量不同）。