— 生理適應 · MEDIUM · MCQ —
一位心臟衰竭病人正在接受靜脈輸液，哪項評估最重要？
Which assessment is most important for a client with a history of heart failure who is receiving intravenous fluids?
- AUrine color尿液顏色
- BLung sounds✓ 正解肺部聽診音
- CSkin turgor皮膚張力
- DAppetite食慾
— Explanation · 中文詳解 —
心臟衰竭（Heart Failure）病人因心臟幫浦功能受損，若靜脈輸液速度過快或容量過大，極易導致液體滯留，進而引發肺水腫（Pulmonary Edema）。肺部聽診是評估液體容積超載（Fluid Volume Overload）最靈敏的指標，護理師應評估是否有濕囉音（Crackles）、呼吸急促或呼吸困難，以確保病人呼吸系統的安全，這是優先於皮膚或食慾評估的臨床重點。
In clients with heart failure, the pump function of the heart is impaired, and IV fluids administered too rapidly or in excessive volume can readily cause fluid retention and pulmonary edema. Auscultation of the lungs is the most sensitive indicator of fluid volume overload; the nurse should assess for crackles, tachypnea, or dyspnea to ensure respiratory safety, which is a clinical priority over assessing the skin or appetite.