# 敗血症組合第6小時護理師重新評估體液與組織灌流。適當之組合後重新評估行動與發現?複選。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=zh-tw  
> language: zh-TW  
> subject: Reduction of Risk Potential  
> category: ROR

## 題目

敗血症組合第6小時護理師重新評估體液與組織灌流。適當之組合後重新評估行動與發現?複選。

1

以PLR或SVV評估流體反應性

2

記錄乳酸趨勢(計算清除率%)

3

監測花斑與微血管回填,合MAP與尿量

4

依培養與source control重新評估抗生素

5

不論容積狀態常規再給30 mL/kg快速注射

## 解析

敗血症第6小時再評估:乳酸趨勢(清除率>10-20%表示復甦適當)、以動態法再評流體反應性(PLR短暫增前負荷、動脈線SVV、IVC超音波) — 靜態如CVP不準。依培養再評抗生素並考量source control(引流、清創)。持續監測組織灌流(花斑、微血管回填、MAP、尿量)。常規再給30 mL/kg錯誤 — 補液依反應性指引;過度復甦惡化結果。

## 深入解析

初始30 mL/kg後採保守流體策略。CLOVERS、CLASSIC試驗支持達灌流目標後降至維持劑量。

## 臨床情境

第6小時。norepinephrine下MAP 64,乳酸4.2→2.8,尿0.4 mL/kg/小時。

## 重要概念

- **PLR** — 床邊以抬腿暫時增前負荷之流體反應性測試。
- **乳酸清除率** — 2-6小時內降低百分比 — 超過10-20%表示復甦適當。
- **感染源控制** — 引流、清創、移除裝置以消除感染源。

## 相同主題題目

- [A 52-year-old patient is admitted with severe acute pancreatitis. Lipase is 1,800 U/L and …](https://mymerci.kr/pages/nclex_q.php?qn_id=372851&lang=zh-tw)
- [A 68-year-old is admitted for acute uncomplicated diverticulitis with WBC 16,000/uL and pe…](https://mymerci.kr/pages/nclex_q.php?qn_id=372855&lang=zh-tw)
- [A patient with end-stage renal disease is post-op day 1 from a left forearm arteriovenous …](https://mymerci.kr/pages/nclex_q.php?qn_id=373261&lang=zh-tw)
- [A 72-year-old presents to the ED with sudden right-sided weakness and aphasia. Family stat…](https://mymerci.kr/pages/nclex_q.php?qn_id=373516&lang=zh-tw)
- [A 65-year-old is post-op day 1 from a hip arthroplasty. Which nursing action best supports…](https://mymerci.kr/pages/nclex_q.php?qn_id=373882&lang=zh-tw)
- [A nurse is implementing the CDC STEADI fall-prevention initiative for community-dwelling o…](https://mymerci.kr/pages/nclex_q.php?qn_id=374875&lang=zh-tw)
- [A patient on day 7 of heparin therapy has a platelet count drop from 220,000 to 80,000 ove…](https://mymerci.kr/pages/nclex_q.php?qn_id=374929&lang=zh-tw)
- [An 18-year-old with sickle cell disease arrives in vaso-occlusive crisis with severe back …](https://mymerci.kr/pages/nclex_q.php?qn_id=374972&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375147&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_