— 降低風險 · EASY · SATA —
護理師護理一位有心衰竭病史的病人。哪些發現暗示病人可能出現體液過載？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which findings suggest that the client may be experiencing fluid overload? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強勁
- BDistended neck veins✓ 正解頸靜脈怒張
- CDecreased urine output尿量減少
- DCrackles in the lung bases✓ 正解肺底啰音
- EWeight loss of 1 lb in 24 hours24 小時內體重減輕 1 磅
— Explanation · 中文詳解 —
體液過載在心衰竭病人身上常見的表徵包括頸靜脈怒張（JVD）、聽診肺部有囉音（Crackles，代表肺水腫）、脈搏增強（Bounding pulse，因血量增加）。體重增加與尿量減少亦為指標，但選項 E 為體重減輕，故不正確。
Fluid overload in heart failure manifests as increased circulating volume, leading to a bounding pulse, distended neck veins due to venous congestion, and crackles in the lung bases from pulmonary edema. While decreased urine output is also a sign of fluid retention, weight loss is incorrect as fluid overload causes weight gain.
✦ 台美臨床差異
無臨床差異。