護理師照顧一位有心臟衰竭病史的患者。下列哪些發現暗示可能出現液體超載的併發症？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which of the following findings would indicate a potential complication of fluid overload? (Select all that apply.)
- ADevelopment of a new S3 heart sound✓ 正解出現新的第三心音（S3）
- BFine crackles heard on lung auscultation✓ 正解聽診肺部可聞及細小爆裂音
- CIncreased blood pressure✓ 正解血壓升高
- DJugular venous distention (JVD)✓ 正解頸靜脈怒張（JVD）
- EWeight loss of 1 kg in 24 hours24小時內體重減輕1公斤
心臟衰竭病人的液體超載會導致全身與肺部灌流壓力改變。S3 心音（奔馬律）是心室容量過載的早期聽診徵兆。肺部聽診發現細濕囉音（Fine crackles）代表液體已滲出至肺泡，是肺水腫的前兆。頸靜脈怒張（JVD）顯示右心室壓力升高，導致靜脈回流受阻。血壓上升通常是因為血管內容積增加所致。體重減輕 1 kg（選項 E）反而代表液體流失或水分排泄，是治療心衰竭時所預期的良好進展，而非液體超載。護理師應針對這些徵兆採取立即行動，包括抬高床頭、給予利尿劑與限制水分攝取，並監測血氧與呼吸狀況，以避免病情急速惡化。
Fluid overload in clients with heart failure alters systemic and pulmonary perfusion pressures. An S3 heart sound (gallop) is an early auscultatory sign of ventricular volume overload. Fine crackles heard on lung auscultation indicate that fluid has leaked into the alveoli, which is a precursor of pulmonary edema. Jugular venous distention (JVD) reflects elevated right ventricular pressure and impaired venous return. Increased blood pressure usually results from increased intravascular volume. Weight loss of 1 kg (option E) actually represents fluid loss or excretion and is a positive response expected during heart failure treatment, not a sign of fluid overload. The nurse should take immediate action in response to these signs, including elevating the head of the bed, administering diuretics, restricting fluid intake, and monitoring oxygen saturation and respiratory status to prevent rapid deterioration.
美國護理師在進行身體評估時，對於 S3 心音與 JVD 的辨識能力通常要求較高，並常納入護理紀錄。台灣臨床作業中，護理師較常由醫師確認聽診異常，並透過每日監測入出量與體重來評估，對於聽診技巧的依賴程度略有不同。