— 生理適應 · EASY · MCQ —
病人呈現體液容積過多徵象，護理師的首要介入措施為何？
A client presents with signs of fluid volume excess. Which intervention is the highest priority for the nurse?
- AAuscultate lung sounds✓ 正解聽診肺部呼吸音
- BMeasure intake and output測量攝入量與排出量
- CWeigh the client daily每日稱重
- DAdminister furosemide as ordered依指示給予呋塞米
— Explanation · 中文詳解 —
體液容積過多最嚴重的風險為肺水腫，因此優先評估呼吸系統狀況是護理評估的核心。聽診肺部有無濕囉音能及早發現肺部積水，這直接關係到病人的呼吸狀態。藥物給予與量測數據雖重要，但在確認呼吸道安全性與氣體交換狀況之後進行。
The most serious risk in fluid volume excess is pulmonary edema; therefore, priority assessment of the respiratory system is the core of nursing assessment. Auscultating the lungs for the presence of crackles allows for early detection of pulmonary fluid accumulation, which directly relates to the client's respiratory status. Although medication administration and quantitative data are important, they should be performed only after airway safety and gas exchange have been confirmed.
✦ 台美臨床差異
無顯著差異。