— 降低風險 · MEDIUM · SATA —
一位有心衰竭病史的病人正在接受靜脈輸液推注（bolus），哪些發現暗示水分過負荷？（選所有適合的）
A nurse is caring for a client with a history of heart failure who is receiving an IV bolus. Which findings suggest fluid overload? (Select all that apply.)
- AIncreased blood pressure✓ 正解血壓升高
- BBounding pulse✓ 正解脈搏有力
- CDry mucous membranes黏膜乾燥
- DCrackles in the lungs✓ 正解肺部濕囉音
- EFlattened neck veins頸靜脈扁平
— Explanation · 中文詳解 —
心衰竭病人接受快速輸液時，血壓升高、脈搏有力及肺部濕囉音均可能反映循環血容量增加與肺鬱血。黏膜乾燥和頸靜脈扁平較符合體液不足。若輸液期間出現肺部濕囉音或呼吸困難，應立即停止或減慢輸液並依病況通知醫療團隊。
Fluid overload in clients with heart failure manifests through multiple signs, including crackles indicating pulmonary edema, bounding pulses from increased vascular volume, and elevated blood pressure. Since all listed options are consistent with acute fluid volume excess, the nurse must recognize these findings as urgent indicators requiring immediate intervention such as slowing or stopping the IV infusion.
✦ 台美臨床差異
美台護理師皆接受針對高危險族群使用輸液泵（Infusion pump）並嚴密監測心肺功能的訓練。