— 基本照護與舒適 · MEDIUM · SATA —
一位心衰竭病人，護理師應監測哪些液體滯留（Fluid overload）的跡象？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which signs of fluid overload should the nurse monitor for? (Select all that apply.)
- ACrackles in the lungs✓ 正解肺部濕囉音
- BBounding pulse✓ 正解強而有力的脈搏
- CJugular vein distension (JVD)✓ 正解頸靜脈怒張 (JVD)
- DDecreased blood pressure血壓下降
- EWeight gain✓ 正解體重增加
— Explanation · 中文詳解 —
液體過量會導致血管內壓力升高，表現為頸靜脈怒張（JVD）、肺部濕囉音（Crackles，代表肺水腫）、強而有力的脈搏（Bounding pulse）以及體重增加。血壓通常會因循環液量增加而升高，而非下降（除非處於心源性休克後期）。
Fluid overload increases intravascular pressure, presenting as jugular vein distension (JVD), pulmonary crackles (pulmonary edema), bounding pulse, and weight gain. Blood pressure usually rises with increased circulating volume rather than dropping (unless in late cardiogenic shock).
✦ 台美臨床差異
美台臨床對心衰竭體液管理監測重點一致，均重視體重與出入量平衡。