— 降低風險 · EASY · MCQ —
護理師照護一位剛完成腹部手術的病人，下列哪項發現需優先回報給外科醫師？
A nurse is caring for a client who has just returned from an abdominal surgery. Which finding is the most priority to report to the surgeon?
- AUrine output 20 mL/hour over the last 2 hours✓ 正解過去兩小時的尿液輸出量為 20 mL/小時
- BBlood pressure 100/60 mmHg血壓 100/60 mmHg
- CAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- DModerate serosanguineous drainage on the surgical dressing手術敷料上有中等量的漿液血性滲出液
— Explanation · 中文詳解 —
術後尿量是評估組織灌流與體液容積的重要指標。小於 30 mL/hr 通常代表腎臟灌流不足，可能由低血容積休克或術中失血引起，屬高風險狀況。其他選項：B 為邊緣性血壓，C 為術後常見之腸麻痺，D 為正常滲出表現。
Urine output is a critical indicator of renal perfusion and overall fluid volume status after surgery. An output of less than 30 mL/hour suggests inadequate perfusion, potentially due to hypovolemia or hemorrhage, and requires immediate reporting. Other findings such as moderate drainage or absent bowel sounds are common and expected in the immediate postoperative period.
✦ 台美臨床差異
美國護理師對監測輸入輸出量有較高自主權，台灣護理師亦密切監測，但在回報尿量過低時，常需配合醫師查房時間處理。