— 降低風險 · EASY · MCQ —
一位病人腹部手術後 4 小時。護理師應立即向醫療團隊報告哪項評估發現？
A client is 4 hours post-abdominal surgery. Which assessment finding should the nurse report to the healthcare provider immediately?
- AAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- BUrine output of 20 mL/hr for the last two hours✓ 正解過去兩小時尿量為 20 mL/hr
- CSerosanguineous drainage on the surgical dressing手術敷料上有漿液血性引流液
- DPain rating of 6 out of 10疼痛評分 6/10
— Explanation · 中文詳解 —
術後尿量應維持在至少 30 mL/hr。連續兩小時尿量低於 20 mL/hr 可能預示低血容積（休克）或急性腎損傷，為風險降低的關鍵警訊。B（疼痛）為術後預期現象；C（腸音消失）在術後初期常見；D（漿液血性滲液）為術後初期傷口正常引流，非緊急狀況。
Urine output less than 30 mL/hr indicates inadequate renal perfusion and may signal hypovolemia or shock, requiring immediate provider notification. While absent bowel sounds, serosanguineous drainage, and expected postoperative pain are normal findings in the early postoperative period, oliguria is a critical sign of hemodynamic instability.
✦ 台美臨床差異
台美對術後尿量 30 mL/hr 的標準一致，但美國護理師對低尿量可能更早啟動 fluid bolus 醫囑（PRN）。