— 基本照護與舒適 · MEDIUM · SATA —
護理師正為心臟衰竭病人提供出院指導。應包含哪些監測水分狀態的措施？（選所有適合的）
A nurse is providing discharge instructions to a client with heart failure. Which actions should the nurse include to monitor fluid status? (Select all that apply.)
- AWeigh yourself daily at the same time each morning✓ 正解每天早晨同一時間測量體重
- BReport a weight gain of 3 lbs (1.4 kg) in 2 days✓ 正解2天內體重增加3磅（1.4公斤）時予以回報
- CCheck for swelling in the ankles and feet✓ 正解檢查腳踝與腳部是否有水腫
- DIncrease sodium intake to improve thirst增加鈉攝取量以改善口渴感
- ELimit fluid intake as directed by the provider✓ 正解遵照醫師指示限制液體攝取
— Explanation · 中文詳解 —
本題考驗護理師對心臟衰竭（heart failure）病人出院衛教的理解，特別是關於監測水分狀態的措施。核心概念是心臟衰竭病人容易發生體液過多（fluid overload），導致水腫、呼吸困難等症狀，甚至引發急性心臟衰竭惡化。因此，病人需要學習自我監測體液狀態，以便早期發現並回報異常，及時調整治療。衛教內容應包括每日固定時間量體重、監測水腫、了解體重快速增加的危險信號，以及遵從醫囑限制鈉和液體攝取，以有效管理病情並預防再入院。
Daily weight monitoring at the same time is the most sensitive indicator of fluid status changes in heart failure patients. Clients should report sudden weight gains (e.g., 3 lbs in 2 days) and check for dependent edema, while strictly limiting sodium and fluid intake as prescribed to prevent volume overload.