— 生理適應 · MEDIUM · MCQ —
護理師照護一位急性低血容性休克的病人，哪項評估結果最能顯示液體復甦有效？
A nurse is caring for a client with acute hypovolemic shock. Which assessment finding is the most reliable indicator of effective fluid resuscitation?
- ABlood pressure of 110/70 mmHg血壓 110/70 mmHg
- BHeart rate of 88 beats per minute心率每分鐘 88 次
- CCapillary refill time of 2 seconds毛細血管回充時間 2 秒
- DUrine output of 30 mL/hour✓ 正解尿量每小時 30 mL
— Explanation · 中文詳解 —
尿量是反映組織灌流與腎臟血流的關鍵指標。當休克緩解，腎臟灌流恢復，尿量通常會達到每小時 30 mL 以上，這是判斷循環穩定最可靠的臨床數據。血壓、心率與微血管回充時間易受疼痛、焦慮或周邊血管阻力影響，敏感度不如尿量。
Urine output is the most reliable indicator of effective fluid resuscitation in hypovolemic shock because it reflects restored renal perfusion and systemic circulation. While blood pressure, heart rate, and capillary refill are useful, they can be influenced by pain, anxiety, or ambient temperature, making them less sensitive indicators of tissue perfusion compared to urine output.
✦ 台美臨床差異
美國常使用中心靜脈壓（CVP）或心輸出量監測，台灣臨床則更依賴 hourly urine output 與臨床表徵來調整輸液。