哪一項評估結果在有心衰竭病史的病人身上,需要護理師立即處置?
Which assessment finding in a client with a history of heart failure requires immediate intervention by the nurse?
- ASudden onset of dyspnea and pink frothy sputum✓ 正解突發性呼吸困難和粉紅色泡沫痰
- BFine crackles heard in the lung bases在肺基部聽到細濕囉音
- CPeripheral edema周邊水腫
- DWeight gain of 1 lb in 2 days兩天內體重增加 1 磅
急性肺水腫(Acute Pulmonary Edema)是心衰竭的緊急併發症,表現為急性呼吸困難、粉紅色泡沫痰。這是因為左心室無法有效排出血液,導致肺微血管壓力升高,液體滲入肺泡。病人隨時有窒息風險,護理師應立即採取緊急措施:坐姿以減少靜脈回流、給予高流量氧氣、準備利尿劑、並通知醫療團隊進行緊急搶救。
Acute pulmonary edema is an emergent complication of heart failure, presenting with acute dyspnea and pink, frothy sputum. It occurs because the left ventricle cannot effectively eject blood, raising pulmonary capillary pressure and allowing fluid to leak into the alveoli. The client is at imminent risk of asphyxiation, and the nurse must initiate emergency measures immediately: place the client in a sitting position to reduce venous return, administer high-flow oxygen, prepare diuretics, and notify the medical team for emergency intervention.