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生理適應 · MEDIUM · SATA

護理師照顧一位肺炎病人,下列哪些護理措施能促進生理適應?(選所有適合的)

A nurse is caring for a client with pneumonia. Which nursing interventions should be implemented to support physiological adaptation? (Select all that apply.)

  • AEncourage deep breathing and coughing exercises✓ 正解
    鼓勵深呼吸與咳嗽運動
  • BMaintain a semi-Fowler's position✓ 正解
    維持半坐臥位
  • CRestrict fluid intake to prevent pulmonary edema
    限制水分攝取以預防肺水腫
  • DAdminister antipyretics as ordered for fever✓ 正解
    依醫囑給予退燒藥以處理發燒
  • EMonitor oxygen saturation levels✓ 正解
    監測血氧飽和度
Explanation · 中文詳解

肺炎病人需保持呼吸道通暢(呼吸訓練),維持半坐臥位以利橫膈下降擴張肺部,發燒需監控並給予退燒藥以降低代謝壓力,並持續追蹤血氧以評估氣體交換狀態。限制液體攝入不正確,肺炎病人需適當補水以稀釋呼吸道分泌物,除非有特定禁忌。

Clients with pneumonia need to maintain airway patency (breathing exercises), keep a semi-Fowler's position to allow diaphragmatic descent and lung expansion, monitor fever and administer antipyretics as ordered to reduce metabolic stress, and continuously monitor oxygen saturation to assess gas exchange. Restricting fluid intake is incorrect; pneumonia patients should be encouraged to take in adequate fluids to thin respiratory secretions, unless specifically contraindicated.

✦ 台美臨床差異

台灣醫院常規會強調胸腔物理治療及姿位引流,美國則更依賴鼓勵病人活動及使用誘發性肺量計(Incentive Spirometry)。

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