# 一位 70 公斤的橫紋肌溶解症個案正在接受醫囑等張靜脈輸液。下列哪項發現最能顯示輸液治療達到預期目標且未造成體液過負荷？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=498698&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

一位 70 公斤的橫紋肌溶解症個案正在接受醫囑等張靜脈輸液。下列哪項發現最能顯示輸液治療達到預期目標且未造成體液過負荷？

## 選項

1. 尿量為 20 mL/hr，且血清肌酸酐正在上升
2. 尿量為 350 mL/hr，且出現新的雙側囉音
3. 尿量為 100 mL/hr，且前肺音保持清晰 **✔ 正確答案**
4. 無尿，且下垂性水腫變得更明顯

**正確答案: 3**

## 解析

針對橫紋肌溶解症的目標導向輸液治療，利用尿量來支持腎臟灌流，同時避免體液過負荷。此個案的尿量在建議的體重基礎範圍內，且清晰的肺音表示目前無肺充血。

## 深入解析

快速解答
尿量在治療目標範圍內，且肺部保持清晰，顯示復甦足夠且無明顯過負荷。

為什麼這是正確的
橫紋肌溶解症釋放的肌紅蛋白可能傷害腎臟，因此滴定等張輸液以維持腎血流。尿量在醫囑的體重基礎目標內支持有效性，而清晰的肺音支持對輸液的耐受性。

簡單比喻或心智圖像
輸液治療就像沖洗排水管中的碎屑，同時觀察水槽是否溢出。尿量代表流量，肺部評估有助於偵測溢出，但此類比不能取代電解質、肌酸酐和血液動力學監測。

記憶掛鉤
橫紋肌溶解症輸液需要足夠的尿流，且無體液過負荷的徵象。

NCLEX 決策規則
評估橫紋肌溶解症的輸液復甦時，將目標導向的尿量與過負荷評估配對。低或無尿量暗示腎清除不足，而新的囉音警告單純增加輸液可能有害。

為什麼其他選項是錯的
低尿量伴隨肌酸酐上升暗示腎損傷。高尿量伴隨囉音表示輸液耐受性差，而無尿伴隨水腫增加顯示額外未經判斷的輸液可能惡化過負荷。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]AAST: Rhabdomyolysis Clinical Consensus DocumentAmerican Association for the Surgery of Trauma Critical Care Committee

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