一位 70 歲心衰竭病人入院，護理師發現下肢水腫與肺部濕囉音（Crackles）。護理師的首要行動為何？
A 70-year-old client is admitted with heart failure. The nurse notes dependent edema and crackles in the lungs. What is the nurse's priority?
- AWeigh the client daily每日稱量病人體重
- BEncourage fluid intake鼓勵病人攝取水分
- CApply compression stockings穿戴彈性襪
- DAdminister ordered diuretics✓ 正解給予醫師指示的利尿劑
心衰竭病人的肺部濕囉音（Crackles）代表液體已滲出至肺泡，屬於嚴重肺水腫徵象，極易導致呼吸衰竭。利尿劑（如 Furosemide）能促進水分排出，降低血管內容積與心臟前負荷，是減輕肺部液體負荷最直接且有效的醫療介入。其他行動如稱重、彈性襪等雖屬重要照護，但在急性呼吸窘迫症狀下，給予利尿劑是首要處置。
Crackles in the lungs of a heart failure patient indicate that fluid has leaked into the alveoli, representing severe pulmonary edema, which can readily lead to respiratory failure. Diuretics (such as furosemide) promote water excretion, reducing intravascular volume and cardiac preload, and are the most direct and effective medical intervention to relieve pulmonary fluid overload. Other actions such as weighing the patient or using compression stockings, although important aspects of care, are not the priority when the patient is in acute respiratory distress; administering a diuretic is the top priority.