— 生理適應 · MEDIUM · SATA —
病人接受靜脈輸液治療時，下列哪些評估發現應提醒護理師注意液體過量？（選所有適合的）
Which assessment findings should alert the nurse to the development of fluid volume overload in a client receiving IV therapy? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BCrackles upon lung auscultation✓ 正解聽診肺部有囉音
- CDecreased blood pressure血壓下降
- DNeck vein distention✓ 正解頸靜脈怒張
- EShortness of breath✓ 正解呼吸困難
— Explanation · 中文詳解 —
液體過量（Hypervolemia）表現為血管內容物增加。頸靜脈怒張、心跳強有力、呼吸困難與肺部濕囉音（Crackles）均是心臟負荷增加的指標。血壓通常會因循環血量過多而上升，而非下降（選項 C 為脫水表現）。
Fluid volume overload manifests with signs of increased circulatory capacity, including bounding pulses, neck vein distention, crackles in the lungs, and shortness of breath. These symptoms result from the heart's inability to manage the excess intravascular volume, leading to pulmonary congestion and elevated central venous pressure.
✦ 台美臨床差異
兩地護理標準皆強調執行輸液前必須評估病人心肺狀況，特別是老年人，以防醫源性體液過量。