一位有心臟衰竭病史的病人正在接受每小時 150 mL 的生理食鹽水靜脈輸注。病人突然出現呼吸短促、肺部囉音，以及咳出粉紅色泡沫痰。護理師應首先採取哪項措施？
A nurse is caring for a client with a history of heart failure who is receiving an IV infusion of normal saline at 150 mL/hr. The client suddenly develops shortness of breath, crackles in the lungs, and a cough with frothy, pink-tinged sputum. Which action should the nurse take first?
- ANotify the healthcare provider of the change in status通知醫療提供者病人狀況改變
- BPlace the client in a high-Fowler's position✓ 正解讓病人採取高福勒氏臥位
- CAdminister the prescribed PRN diuretic給予處方之備用利尿劑
- DSlow the IV infusion rate to a keep-vein-open (KVO) rate將靜脈輸注速率減慢至維持靜脈通暢（KVO）速率
病人出現了急性肺水腫（Acute Pulmonary Edema）的典型徵象：呼吸困難、囉音及粉紅色泡沫痰，這通常是液體過負荷（Fluid Overload）引起的。根據 NCLEX 的優先順序原則，當病人出現急性呼吸窘迫時，首要動作是透過姿勢調整（Positioning）來緩解症狀。將病人置於高坐臥位（High-Fowler's）可以利用重力讓液體沉積在肺底，減少回心血量（前負荷），並增加肺部擴張空間，這是最快速、不需醫囑且能立即改善氧合的介入措施。雖然減慢點滴速度（D）也很重要，但它不能立即緩解已經存在的肺部積水。給予利尿劑（C）和通知醫師（A）是後續必要的醫療處置。此題體現了「ABC」原則中的 Breathing，即透過姿勢優化來穩定呼吸狀態。
The client is exhibiting classic signs of acute pulmonary edema: dyspnea, crackles, and pink, frothy sputum—usually caused by fluid overload. According to NCLEX priority-setting principles, when a client is in acute respiratory distress, the first action is to relieve symptoms through positioning. Placing the client in High-Fowler's position uses gravity to allow fluid to settle in the lung bases, decreases venous return (preload), and increases space for lung expansion; this is the fastest intervention, requires no order, and immediately improves oxygenation. Slowing the IV infusion (D) is also important but does not immediately relieve existing pulmonary congestion. Administering a diuretic (C) and notifying the provider (A) are necessary subsequent medical actions. This question reflects the "B" (Breathing) in the ABC principle—stabilizing respiratory status through optimal positioning.
在美國護理實務中，遇到這種情況護理師會立即將病人坐起並給氧，然後才通報；台灣臨床情境下，護理師往往會同時呼叫同事通知醫師並準備藥物，但 NCLEX 考試要求選出單一「最優先」的物理性護理動作。