A nurse is caring for a postoperative patient who suddenly b… | 마이메르시 MyMerci
Fundamentals
문제

A nurse is caring for a postoperative patient who suddenly becomes restless, with decreased urine output and cool, clammy skin, indicating signs of shock. Which assessment finding would be the MOST critical indicator requiring immediate intervention?

The nurse notices the patient has become restless, with decreased urine output and cool, clammy skin.
해설
Hypotension with compensatory tachycardia and weak pulse indicates cardiovascular compromise requiring immediate intervention to prevent organ failure. Other findings (respiratory distress, mild fever, slight hypoxia) are concerning but less immediately life-threatening.

심화 해설

護理學核心解析 這道題目在考驗護理師對於休克 (Shock)狀態下，危及生命徵象的優先順序判斷。題幹已描述患者術後出現躁動不安 (Restlessness)、尿量減少 (Decreased urine output)、皮膚濕冷 (Cool, clammy skin)，這些都是休克（特別是低血容性休克）的典型徵象。此時，護理師必須快速評估並找出最需要立即處理的關鍵問題。 核心概念分析 (Key Concept) 休克的本質是組織灌流不足 (Inadequate tissue perfusion)，導致細胞缺氧與器官功能障礙。評估休克的嚴重度與進程，必須緊密監測核心！生命徵象 (Vital signs)與終端器官灌流指標 (End-organ perfusion indicators)（如意識狀態、尿量、皮膚狀況）。在休克早期，身體會啟動代償機制（如心跳加快、血管收縮）以維持血壓；當代償失效，血壓開始下降時，表示已進入失償性休克 (Decompensated shock)，是立即危及生命的警訊。 正確答案依據 (Answer Rationale) 選項① 血壓 80/50 mmHg 合併 脈搏微弱細速 120 bpm，是核心！失償性休克最明確的指標。 - 收縮壓 80 mmHg 已遠低於正常下限（通常

임상 시나리오

護理臨床實務指南 臨床情境 (Clinical Scenario) 您在外科病房照顧一位剛完成腹部手術返回病房2小時的60歲男性患者。護理紀錄顯示他起初生命徵象穩定，但您進行常規評估時，發現他變得躁動不安，抱怨口渴。觸摸其四肢感覺濕冷，查看尿袋發現過去一小時尿量只有15 mL（體重70kg，遠低於0.5 mL/kg/hr的標準）。您立即測量生命徵象，得到BP 80/50 mmHg, HR 120 bpm且脈搏微弱，RR 28次/分，SpO2 92%。 護理處置策略 (Nursing Intervention) 核心！ 此時應立即啟動緊急應變系統（呼叫團隊、準備急救車），並遵循以下步驟： 1. 評估 (Assessment)：快速檢查手術傷口敷料有無大量滲血、引流管引流量是否突然增加（懷疑術後出血）。同時讓患者平躺，抬高下肢（休克臥位），以增加靜脈回流量。 2. 護理目標設定 (Goal Setting)：立即目標是恢復足夠的組織灌流，具體指標為將收縮壓提升至 >90 mmHg，心率下降至

핵심 개념

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기
App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.