— 基本照護與舒適 · MEDIUM · MCQ —
一位接受靜脈輸液的病人,哪項是液體過載(Fluid overload)的徵象?
Which of the following is a symptom of fluid overload in a client receiving IV fluids?
- APoor skin turgor皮膚彈性不佳
- BBounding pulse✓ 正解脈搏強而有力
- CHypotension低血壓
- DDry mucous membranes黏膜乾燥
— Explanation · 中文詳解 —
靜脈輸液過載(Fluid volume excess)會造成血管內壓力增加。臨床上,護理師應監測病人的心肺狀態。搏動強而有力(Bounding pulse)是因為循環血量增加導致血管壁張力上升。其他相關徵象包括頸靜脈怒張(JVD)、呼吸困難(Dyspnea)、肺部濕囉音(Crackles)以及全身性水腫。
Intravenous fluid overload (fluid volume excess) raises intravascular pressure. Clinically, the nurse should monitor the client's cardiopulmonary status. A bounding pulse arises from increased circulating volume and elevated vascular wall tension. Other associated findings include jugular venous distention (JVD), dyspnea, pulmonary crackles, and generalized edema.