— 生理適應 · MEDIUM · MCQ —
一位有心臟衰竭病史的病人出現呼吸困難與粉紅色泡沫痰。最可能發生了什麼情況？
A client with a history of heart failure presents with dyspnea and pink, frothy sputum. Which condition is most likely occurring?
- APulmonary embolism肺栓塞
- BPulmonary edema✓ 正解肺水腫
- CChronic bronchitis慢性支氣管炎
- DPneumonia肺炎
— Explanation · 中文詳解 —
有心臟衰竭病史的病人出現呼吸困難和粉紅色泡沫痰 (pink, frothy sputum)，這是急性肺水腫 (acute pulmonary edema) 的典型且危險的徵兆。急性肺水腫通常由左心衰竭引起，當左心室無法有效泵血時，血液會在肺循環中積聚，導致肺毛細血管壓力升高，液體滲漏到肺泡和間質空間。滲出的液體與空氣混合，並可能帶有少量紅血球，形成粉紅色的泡沫狀痰液。這是一種需要緊急醫療介入的呼吸急症，護理師應立即辨識並協助處理。
Pink, frothy sputum combined with dyspnea in a client with heart failure is a classic sign of acute pulmonary edema. This condition occurs when left ventricular failure causes fluid to back up into the lungs, increasing capillary pressure and forcing fluid into the alveoli. Immediate nursing intervention is required to manage this life-threatening respiratory emergency.