— 生理適應 · EASY · MCQ —
一位有心衰竭病史的病人，哪項發現暗示有體液過多（Fluid volume overload）？
Which assessment finding in a client with a history of heart failure suggests fluid volume overload?
- ADry mucous membranes黏膜乾燥
- BHypotension低血壓
- CCrackles in the lung bases✓ 正解肺底出現捻发音（濕囉音）
- DIncreased urine output尿量增加
— Explanation · 中文詳解 —
心衰竭（Heart Failure）病人因心臟泵血功能受損，導致液體滯留於肺循環與周邊組織。肺部出現濕囉音（Crackles）是體液過多（Fluid volume overload）最典型的徵象，代表液體滲漏至肺泡中。護理師需評估病人有無呼吸困難、頸靜脈怒張、水腫及體重增加等臨床表現，並監測進出水量與利尿劑療效。
In heart failure, impaired pumping causes fluid to accumulate in the pulmonary circulation and peripheral tissues. Crackles on lung auscultation are a classic sign of fluid volume overload, indicating fluid leakage into the alveoli. The nurse should assess for dyspnea, jugular venous distention, edema, and weight gain, and monitor intake/output and diuretic response.