— 照護管理 · MEDIUM · MCQ —
護理師正在收治一位肺炎病人，病人有有效咳嗽但難以咳出濃稠痰液。護理師應執行哪項措施？
A nurse is admitting a client with pneumonia. The client has a productive cough and is having difficulty expectorating thick sputum. Which intervention should the nurse implement?
- AAdminister cough suppressants給予鎮咳劑
- BHave the client rest in a supine position讓病人採取仰臥姿勢休息
- CRestrict fluid intake to prevent worsening secretions限制水分攝取以防止分泌物惡化
- DEncourage increased fluid intake and ambulation✓ 正解鼓勵增加水分攝取並下床活動
— Explanation · 中文詳解 —
肺炎病人常因發炎反應導致痰液變得濃稠，難以咳出，進而阻塞呼吸道。鼓勵多補充水分（若無禁忌）能有效稀釋痰液，降低黏稠度，使其更容易被咳出。鼓勵下床活動（Ambulation）能增加肺活量並刺激咳嗽反射，幫助清除呼吸道分泌物。鎮咳劑（A）會抑制痰液排出，通常不建議使用；限制水分（C）會加重痰液濃稠；臥床（B）不利於肺部擴張與排痰。
Pneumonia thickens secretions, making airway clearance difficult. Encouraging increased fluid intake (if not contraindicated) thins secretions, while ambulation expands lung volume and stimulates an effective cough. Cough suppressants impair clearance, fluid restriction worsens viscosity, and a supine position decreases lung expansion.