— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師給予心衰竭病人靜脈輸液。首要評估指標為何？
A nurse is administering intravenous fluids to a client with heart failure. Which is the priority assessment?
- ALung sounds✓ 正解肺部聽診音
- BCapillary refill微血管充盈時間
- CSkin turgor皮膚彈性
- DUrine color尿液顏色
— Explanation · 中文詳解 —
心衰竭（Heart Failure）病人的心肌收縮力減弱，對液體容積負荷的耐受力極差。靜脈輸液過快極易引發液體過負荷（Fluid Overload），導致肺水腫（Pulmonary Edema）。肺部聽診發現囉音（Crackles）是液體鬱積於肺泡的早期徵兆，屬於 ABC（Airway, Breathing, Circulation）原則中呼吸相關的優先評估項目，必須最先處理。
Clients with heart failure have reduced myocardial contractility and very poor tolerance for fluid volume overload. Rapid IV infusion easily precipitates fluid overload and pulmonary edema. Crackles auscultated in the lungs are an early sign of alveolar fluid accumulation; this is the priority finding under the ABC (Airway, Breathing, Circulation) principle and must be addressed first.