— 基本照護與舒適 · HARD · MCQ —
一位深二度至三度燒傷的病人，下列哪項評估結果顯示輸液復甦成功？
Which assessment finding in a client with a full-thickness burn indicates successful fluid resuscitation?
- AUrine output of 0.5 mL/kg/hr✓ 正解尿量 0.5 mL/kg/hr
- BHeart rate of 110 beats per minute心率 110 次/分
- CBlood pressure of 90/60 mmHg血壓 90/60 mmHg
- DSerum sodium level of 135 mEq/L血清鈉濃度 135 mEq/L
— Explanation · 中文詳解 —
燒傷病人輸液復甦的黃金指標是尿量。維持每小時 0.5-1.0 mL/kg 的尿量，代表末梢器官灌流充足，且液體已成功進入血管內，未造成嚴重的低血容性休克。其他選項如心跳與血壓會受疼痛、焦慮及藥物影響，非單一反映復甦成效的指標。
Urine output is the most reliable indicator of adequate organ perfusion and successful fluid resuscitation in burn clients. Maintaining a urine output of 0.5 mL/kg/hr ensures that intravascular volume is sufficient to support kidney function. Vital signs like heart rate and blood pressure can be influenced by pain and stress, making them less specific indicators.
✦ 台美臨床差異
美台針對 Parkland 公式與 Parkland-Baxter 公式應用一致，臨床上尿量監測均為標準護理常規。