# 一位護理師正在為一位血壓持續下降且尿量減少的個案進行交班報告。在SBAR的「建議」部分，應包含哪項資訊？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397242&lang=zh-tw  
> language: zh-TW  
> subject: Client Rights  
> category: MOC

## 題目

一位護理師正在為一位血壓持續下降且尿量減少的個案進行交班報告。在SBAR的「建議」部分，應包含哪項資訊？

## 選項

1. 我認為個案需要立即評估是否可能發生休克。 **✔ 正確答案**
2. 個案昨天因肺炎入院。
3. 個案左前臂有一條靜脈管路。
4. 血壓為 86/48 mm Hg，尿量為 15 mL/hr。

**正確答案: 1**

## 解析

SBAR的「建議」部分陳述需要採取什麼行動或回應。血壓下降和尿量減少暗示組織灌流不足，因此需要緊急評估。背景和評估資料雖然重要，但屬於SBAR的其他部分。

## 深入解析

臨床判斷
運用個案線索、時機、檢驗數據及安全風險，選擇最符合「病情惡化之SBAR建議」情境的回應。

記憶提示
將最強的線索群組與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
針對「病情惡化之SBAR建議」，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **SBAR** — 一種結構化的溝通格式：現況、背景、評估、建議。
- **交班** — 臨床人員之間轉移個案資訊與責任。
- **建議** — 在SBAR溝通中，所請求的下一步驟或行動。

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