一位有心臟衰竭病史的病人，兩天內體重增加 5 磅，護理師應優先採取何種措施？
A nurse is assessing a client with a history of heart failure who reports a 5 lb weight gain over 2 days. Which action is the priority?
- ACheck pedal pulses檢查足背動脈搏動
- BReview dietary sodium intake檢視飲食鈉攝取量
- CAdminister the scheduled diuretic按時給予利尿劑
- DAuscultate lung sounds✓ 正解聽診肺部呼吸音
心臟衰竭（Heart Failure, HF）病人若在短時間內體重快速增加，通常代表體內液體滯留（Fluid retention）。在護理評估中，依據 ABC（呼吸道、呼吸、循環）優先順序，呼吸功能最為關鍵。體液過多可能導致肺水腫（Pulmonary edema），因此聽診肺部是否有濕囉音（Crackles）是評估呼吸狀態的首要動作。其他選項雖與 HF 管理有關，但並非評估生命威脅的優先項目。
In clients with heart failure (HF), rapid short-term weight gain usually indicates fluid retention. According to the ABC (Airway, Breathing, Circulation) priority framework, respiratory function is the most critical. Fluid overload may lead to pulmonary edema, so auscultating the lungs for crackles is the priority for assessing respiratory status. The other options are related to HF management but are not priorities for assessing life-threatening complications.