— 基本照護與舒適 · HARD · MCQ —
護理師監測正接受全靜脈營養（TPN）的病人。哪項評估發現應優先處理？
The nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which assessment finding is the priority?
- ASlight redness at the central line insertion site.中心靜脈導管插入部位輕微發紅
- BA blood glucose level of 180 mg/dL.血糖值 180 mg/dL
- CA weight gain of 3 kg (6.6 lbs) over 24 hours.✓ 正解24 小時內體重增加 3 公斤 (6.6 磅)
- DAn oral temperature of 37.5°C (99.5°F).口腔溫度 37.5°C (99.5°F)
— Explanation · 中文詳解 —
TPN 是高張溶液。24 小時內體重暴增 3 公斤（C）強烈暗示發生了「循環負荷過重（Fluid Overload）」，可能導致急性心衰竭或肺水腫，危及生命。血糖 180（B）在 TPN 期間常見，需處理但非最緊急；體重變化是監測液體耐受性最敏感的指標。
TPN is a hypertonic solution. A 3 kg weight gain within 24 hours (C) strongly suggests fluid overload, which can precipitate acute heart failure or pulmonary edema and is life-threatening. A blood glucose of 180 (B) is common during TPN and requires management but is not the most urgent finding; weight change is the most sensitive indicator for monitoring fluid tolerance.
✦ 台美臨床差異
美國護理高度重視 TPN 的併發症（如 Refeeding syndrome）；台灣臨床常將 TPN 簡稱為「大營養」，監測重點雷同。