— 生理適應 · MEDIUM · SATA —
哪項臨床發現顯示術後病人可能出現體液容積過載？（選所有適合的）
Which of the following clinical findings indicates the nurse should suspect fluid volume overload in a post-operative client? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BCrackles on lung auscultation✓ 正解聽診肺部有囉音
- CDecreased blood pressure血壓下降
- DDistended neck veins✓ 正解頸靜脈怒張
- EWeight gain of 1 kg in 24 hours✓ 正解24小時內體重增加1公斤
— Explanation · 中文詳解 —
體液過載會導致血管內壓力增加。臨床特徵包括：脈搏強而有力（Bounding）、肺部聽診出現濕囉音（水分滲入肺泡）、頸靜脈怒張（靜脈回流受阻）以及體重快速增加。低血壓（C）則是體液不足的特徵，而非過載。
Diabetic foot care focuses on preventing injury and infection through daily inspections, wearing properly fitting leather shoes, and using a thermometer to check bathwater temperature due to potential sensory neuropathy. Lotion should be applied to dry areas but avoided between toes to prevent fungal growth, and nails should be cut straight across.
✦ 台美臨床差異
美國護理師常執行床邊身體評估（如聽診肺部），台灣護理師亦會執行但更依賴監測儀器與醫師醫囑。