— 生理適應 · MEDIUM · MCQ —
一位肝硬化合併腹水的病人，護理師應優先採取的照護措施為何？
A nurse is assessing a client with Cirrhosis who has developed ascites. What is the priority nursing intervention?
- AAssess respiratory status✓ 正解評估呼吸狀態
- BProvide a high-protein diet提供高蛋白飲食
- CMonitor daily weights監測每日體重
- DMeasure abdominal girth daily每日測量腹圍
— Explanation · 中文詳解 —
肝硬化合併腹水（Ascites）的病人，最嚴重的潛在威脅在於腹腔內積液過多導致腹壓上升，進而向上推擠橫膈膜（Diaphragm），嚴重限制肺部擴張空間，引發呼吸窘迫（Respiratory distress）。根據 NCLEX 的優先級原則（ABC：Airway, Breathing, Circulation），呼吸狀態的評估必須排在所有測量數值之前。
For a patient with cirrhosis complicated by ascites, the most serious potential threat is excessive intraperitoneal fluid raising intra-abdominal pressure, which pushes the diaphragm upward and severely restricts lung expansion, causing respiratory distress. According to NCLEX priority principles (ABC: Airway, Breathing, Circulation), respiratory status assessment must come before all other measurements.