— 降低風險 · MEDIUM · MCQ —
護理師照護一位有心衰竭病史並進行靜脈點滴輸注的病人，預防併發症的首要評估項目為何？
A nurse is caring for a client with a history of heart failure who is receiving IV fluids. What is the priority assessment to prevent complications?
- AAuscultating the lungs for crackles✓ 正解聽診肺部是否有囉音
- BMeasuring urine output every 8 hours每 8 小時測量尿液輸出量
- CChecking the IV insertion site for phlebitis檢查靜脈注射部位是否有靜脈炎
- DMonitoring blood glucose levels監測血糖水平
— Explanation · 中文詳解 —
心衰竭病人體液過負荷（fluid overload）風險極高，靜脈輸注時首要評估呼吸系統。肺部聽診出現濕囉音（crackles）是液體鬱積於肺部的重要徵象，顯示可能發生肺水腫，此併發症比血管炎或尿量監測更為緊急。
Clients with heart failure are at high risk for fluid overload and pulmonary edema when receiving IV fluids. The priority assessment is auscultating the lungs for crackles, as this provides early detection of fluid accumulation in the lungs, which is more immediate and life-threatening than local site complications or delayed urine output changes.
✦ 台美臨床差異
兩地皆將肺部聽診視為預防心衰竭急性惡化的核心護理能力，重點在於及早辨識異常聲音。