— 降低風險 · EASY · MCQ —
護理師照護一位術後 2 小時腹部子宮切除術的病人，哪項評估結果需要立即介入？
A nurse is caring for a client who is 2 hours post-operative after an abdominal hysterectomy. Which assessment finding requires immediate intervention?
- AReported pain level of 6/10自述疼痛程度為 6/10
- BAbsent bowel sounds in all quadrants各象限腸鳴音消失
- CSerosanguineous drainage on the abdominal dressing腹部敷料上有漿血性引流液
- DUrine output of 20 mL over the last 2 hours✓ 正解過去 2 小時內尿量為 20 mL
— Explanation · 中文詳解 —
術後尿量是評估腎臟灌流與血流動力的重要指標。正常成人尿量至少應維持 30 mL/hr，2 小時僅 20 mL 顯示有少尿情形，可能存在低血容積或休克，必須立即向醫師報告並進行評估。其他選項在術後早期均屬預期內的正常發現。
Urine output less than 30 mL/hr indicates potential hypovolemia or shock due to poor renal perfusion, requiring immediate intervention. Other findings such as moderate pain, absent bowel sounds, and serosanguineous drainage are expected in the early postoperative period.
✦ 台美臨床差異
台美對於術後監測標準一致，皆將 <30mL/hr 視為臨床警訊，但台灣護理師通常會先確認導尿管有無扭曲後再回報醫師。