— 生理適應 · HARD · MCQ —
心衰竭病人呈現肺水腫徵象。首要護理行動為何？
A client with heart failure is showing signs of pulmonary edema. What is the priority nursing action?
- APlace in high-Fowler’s position✓ 正解採取高福勒氏臥位
- BInsert a Foley catheter插入導尿管
- CAdminister IV Morphine靜脈注射嗎啡
- DObtain an EKG取得心電圖 (EKG)
— Explanation · 中文詳解 —
肺水腫（Pulmonary edema）導致肺泡內充滿液體，嚴重阻礙氣體交換。將個案置於高坐位（High-Fowler’s position）能透過重力作用減少靜脈回流至心臟（減少前負荷），同時利用重力使液體沉積於肺部底部，增加肺部上方氣體交換面積，並減輕呼吸肌負擔，是改善呼吸困難最快速的物理介入。
Pulmonary edema fills the alveoli with fluid, severely impairing gas exchange. Placing the patient in a High-Fowler's position uses gravity to reduce venous return to the heart (reducing preload), while gravity also causes fluid to settle at the bases of the lungs, increasing the upper-lung area available for gas exchange and reducing the workload of the respiratory muscles. This is the fastest physical intervention to relieve dyspnea.