對於有心臟衰竭與水腫病史的病人，下列哪些護理措施是適當的？（選所有適合的）
Which nursing interventions are appropriate for a client with a history of heart failure and edema? (Select all that apply.)
- AMonitor daily weights✓ 正解監測每日體重
- BEncourage a high-sodium diet鼓勵高鈉飲食
- CAssess lung sounds for crackles✓ 正解聽診肺部是否有囉音
- DElevate the lower extremities✓ 正解抬高下肢
- ELimit fluid intake as ordered✓ 正解依醫囑限制液體攝取
核心概念：心臟衰竭（Heart Failure, HF）與水腫（Edema）病人的護理。 為何正確答案對： A. 每日監測體重（Monitor daily weights）是評估體液滯留最敏感且客觀的方法。體重在短時間內（如 1-2 天）顯著增加（通常 > 2-3 磅或 1 公斤）是心衰竭惡化的早期徵兆，代表體內液體量過多。 C. 評估肺部囉音（Assess lung sounds for crackles）有助於偵測肺部積液（Pulmonary congestion）或肺水腫（Pulmonary edema）的早期跡象，這是心衰竭失代償的表現。 D. 抬高下肢（Elevate the lower extremities）有助於利用重力促進靜脈回流，減輕周邊水腫，緩解腿部不適。 E. 限制液體攝取（Limit fluid intake as ordered）是控制體液滯留的關鍵措施，尤其是在病人出現明顯水腫或體重增加時，遵從醫囑限制飲水能減輕心臟負荷。 為何其他選項錯： B. 高鈉飲食（Encourage a high-sodium diet）會導致體內鈉滯留，進而引起水分滯留，加重心臟衰竭和水腫，應嚴格限制鈉攝取，而非鼓勵。
Core concept: Nursing care for clients with heart failure (HF) and edema. Why the correct answers are right: A. Monitoring daily weights is the most sensitive and objective method of assessing fluid retention. A significant short-term weight gain (such as more than 2-3 pounds or 1 kg over 1-2 days) is an early sign of worsening heart failure and indicates excess fluid in the body. C. Assessing lung sounds for crackles helps detect early signs of pulmonary congestion or pulmonary edema, which reflect decompensated heart failure. D. Elevating the lower extremities helps use gravity to promote venous return, reduce peripheral edema, and relieve leg discomfort. E. Limiting fluid intake as ordered is a key intervention for controlling fluid retention. Especially when the client has obvious edema or weight gain, adhering to the prescribed fluid restriction reduces cardiac workload. Why the other option is wrong: B. A high-sodium diet causes sodium retention, which leads to fluid retention and worsens heart failure and edema. Sodium intake should be strictly limited rather than encouraged.