護理師評估一位心衰竭病史的個案，發現體重增加及下肢水腫。應採取哪些護理措施？（選所有適合的）
A nurse is assessing a client with a history of heart failure who presents with weight gain and peripheral edema. Which nursing interventions are appropriate? (Select all that apply.)
- AElevate the lower extremities when in bed✓ 正解卧床時抬高下肢
- BMonitor strict intake and output✓ 正解嚴格監測出入量
- CEncourage a low-sodium diet✓ 正解鼓勵低鈉飲食
- DAdminister potassium supplements as prescribed依處方給予鉀離子補充劑
- ERestrict daily fluid intake as ordered✓ 正解依指示限制每日液體攝取量
針對心衰竭導致的體液超載，護理重點在於減少液體回流負荷（抬高下肢）、精確監測液體平衡（I&O）、減輕組織水腫與血管壓力（限鈉限水）。利尿劑常造成鉀離子流失，但補充鉀離子需依據檢驗報告而非針對水腫直接給予，故 D 選項非首選措施。
For fluid overload caused by heart failure, nursing priorities are to reduce venous return load (elevate the lower extremities), accurately monitor fluid balance (I&O), and reduce tissue edema and vascular pressure (sodium and fluid restriction). Diuretics commonly cause potassium loss, but potassium supplementation must be based on laboratory results rather than given empirically for edema, so option D is not the first-line measure.
美國護理師對限水與鈉的衛教非常具體，台灣臨床較常由營養師介入衛教，護理師輔助執行。