— 照護管理 · MEDIUM · MCQ —
一位護理師正在接收入院一位有嚴重脫水的病人。哪項評估發現需要立即介入？
A nurse is admitting a client with severe dehydration. Which assessment finding requires immediate intervention?
- ABlood pressure of 90/50 mmHg✓ 正解血壓 90/50 mmHg
- BUrine output of 20 mL in the last hour最後一小時的尿液輸出量為 20 mL
- CDecreased skin turgor皮膚彈性減退
- DDry mucous membranes黏膜乾燥
— Explanation · 中文詳解 —
嚴重脫水（Severe Dehydration）可能導致低血容性休克（Hypovolemic Shock）。血壓 90/50 mmHg 是嚴重的低血壓徵象，顯示病人的循環系統已代償失調，無法維持足夠的器官灌流。這屬於危急狀態（Critical），若不立即啟動靜脈補液，將導致嚴重的器官損傷或生命危險。相較於黏膜乾燥或尿量減少（這些是脫水的徵兆但非立刻致命），低血壓需護理師優先介入。
A blood pressure of 90/50 mmHg indicates hypotension and potential hypovolemic shock, requiring immediate intervention to restore perfusion. While other signs like dry mucous membranes and low urine output indicate dehydration, they are less immediately life-threatening than hemodynamic instability.