— 生理適應 · HARD · SATA —
一位病人出現低血容性休克的徵象。下列哪些護理措施為優先事項？（選所有適合的）
A client presents with signs of hypovolemic shock. Which nursing interventions are priority? (Select all that apply.)
- AElevate the client's legs✓ 正解抬高病人雙腿
- BInitiate two large-bore IV lines✓ 正解建立兩條大口徑靜脈通路
- CAdminister oxygen via non-rebreather mask✓ 正解透過非再呼吸面罩給予氧氣
- DAdminister high-dose corticosteroids給予高劑量皮質類固醇
- EMonitor hourly urine output✓ 正解監測每小時尿量
— Explanation · 中文詳解 —
低血容性休克（Hypovolemic Shock）是體液流失導致組織灌流不足，護理優先順序遵循 ABC（呼吸道、呼吸、循環）原則。首要目標是恢復血容積與氧合。抬高雙腿可促進靜脈回流，大口徑點滴（Large-bore IV）能確保快速輸液，給氧改善細胞缺氧，而尿量監測則是評估腎臟灌流與液體復甦效果的黃金標準（正常成人應 > 0.5 mL/kg/hr）。
Priority interventions for hypovolemic shock focus on restoring circulating volume and tissue oxygenation. Elevating the legs enhances venous return, while large-bore IVs facilitate rapid fluid resuscitation. Administering oxygen addresses tissue hypoxia, and monitoring hourly urine output serves as a sensitive indicator of renal perfusion.