— 降低風險 · EASY · MCQ —
護理師照護一位剛完成腹部手術的病人，下列哪項發現需優先回報醫師？
A nurse is caring for a client who has just returned from an abdominal surgery. Which finding is the highest priority to report to the surgeon?
- APatient reports pain score of 6/10病人報告疼痛指數為 6/10
- BUrine output of 20 mL/hr over the last 2 hours✓ 正解過去 2 小時的尿液輸出量為 20 mL/hr
- CPresence of hypoactive bowel sounds存在腸蠕動減弱的現象
- DBlood pressure 100/60 mmHg血壓 100/60 mmHg
— Explanation · 中文詳解 —
術後病人尿量是評估組織灌流與腎功能的關鍵指標。成人每小時尿量低於 30 mL（或 <0.5 mL/kg/hr）即被視為少尿（Oliguria），這通常暗示循環血量不足（Hypovolemia）、休克或急性腎損傷。在術後早期，這項數值較血壓波動或腸蠕動減弱更能直接反應病人的生理穩定性與器官灌流情形，必須立即報告醫師。
Urine output below 30 mL/hr indicates oliguria, which is a critical sign of inadequate tissue perfusion, hypovolemia, or renal impairment in the postoperative period. This finding requires immediate reporting as it reflects systemic stability more urgently than expected pain or hypoactive bowel sounds.