一位病患出現體液負荷過重徵象，護理師應執行哪些護理措施？（選所有適合的）
A client presents with signs of fluid volume overload. Which nursing interventions should be implemented? (Select all that apply.)
- AElevate the head of the bed✓ 正解抬高床頭
- BAdminister furosemide as ordered✓ 正解依醫囑給予呋塞米（Furosemide）
- CIncrease intravenous fluid infusion rate增加靜脈輸液滴速
- DMonitor serum electrolytes, especially potassium✓ 正解監測血清電解質，特別是鉀離子
- EAssess lung sounds frequently✓ 正解頻繁評估肺音
體液負荷過重（fluid volume overload）會導致靜脈壓升高、肺水腫及心臟負荷增加。護理目標在於減輕前負荷（preload）、促進水分排出及監測循環狀態。抬高床頭可利用重力減少回心血量並改善呼吸；使用利尿劑（如 furosemide）可直接促進腎臟水分排除；監測電解質（特別是鉀）是因為利尿劑常導致低血鉀，需維持體內平衡；監測肺音則能評估肺水腫改善情形。這些措施皆為臨床護理標準流程。
Fluid volume overload raises venous pressure, causes pulmonary edema, and increases cardiac workload. Nursing goals are reducing preload, promoting fluid excretion, and monitoring circulatory status. Elevating the head of the bed uses gravity to decrease venous return and improve breathing; loop diuretics such as furosemide promote renal water excretion; serum electrolytes (especially potassium) must be monitored because diuretics commonly cause hypokalemia; and lung-sound assessment evaluates pulmonary edema status. These are standard nursing measures.
在美國臨床環境中，針對體液負荷過重，護理師需特別主動監測 Intake & Output（I&O）及每日體重（Daily weight），這通常是標準醫囑的一部分，且護理師需具備判斷何時應扣除或暫停點滴的臨床判斷力。