— 基本照護與舒適 · MEDIUM · MCQ —
一位病人出現脫水症狀，下列哪項評估發現最令護理師擔憂？
A client presents with symptoms of dehydration. Which assessment finding is most concerning to the nurse?
- AIncreased thirst口渴增加
- BSkin turgor of 3 seconds皮膚彈性為 3 秒
- CUrine output of 20 mL/hour✓ 正解尿量 20 mL/小時
- DDry mucous membranes黏膜乾燥
— Explanation · 中文詳解 —
脫水病人最重要的指標為尿量。成人正常尿量至少需 >30 mL/hr，20 mL/hr 顯示腎臟灌流不足或嚴重脫水，可能演變為急性腎損傷，需優先處理。其他如黏膜乾燥、皮膚回彈慢、口渴皆為脫水徵兆，但尿量減少最具臨床警訊價值。
Cloudy dialysate return is the primary indicator of peritonitis, an infection caused by white blood cells and bacteria in the peritoneal cavity. This finding requires immediate medical attention to prevent serious complications such as sepsis. Other options like blood-tinged output in early sessions, clear effluent, or poor drainage due to mechanical issues are not specific signs of infectious peritonitis.
✦ 台美臨床差異
美台對於每小時尿量少於 30 mL 的警示標準一致，但在電子病歷紀錄中美國通常會自動觸發警示系統。