一位有心臟衰竭病史的病人因肺水腫入院。護理師觀察到病人咳出粉紅色泡沫痰，呼吸頻率為 32 次/分。下列哪項護理措施最為優先？
A client with a history of heart failure is admitted with pulmonary edema. The nurse notes the client is coughing up pink, frothy sputum and has a respiratory rate of 32/min. Which intervention is the priority?
- APosition the client in high-Fowler's with legs dependent✓ 正解將病人置於高福勒氏臥位並讓雙腳下垂
- BAdminister furosemide 40 mg IV push as prescribed依醫囑靜脈推注給藥 40 mg furosemide
- CObtain a portable chest X-ray immediately立即進行便携式胸部 X 光檢查
- DPerform oropharyngeal suctioning to clear the airway進行口咽部抽吸以清除呼吸道
肺水腫（Pulmonary Edema）的核心機轉是左心衰竭導致肺毛細血管壓力過高，液體滲入肺泡。處置的首要原則是減少靜脈回流（降低前負荷）並改善通氣。將病人置於高坐臥位（High-Fowler's）並讓雙腳下垂（legs dependent），可利用重力作用使血液淤積在下肢，直接減少回流到心臟的血量，進而減輕肺部充血，這是最快且不需器材的介入。給予利尿劑（B）是標準治療，但藥物發生作用需要時間，不如姿勢改變即時；X光（C）是診斷工具而非治療；粉紅色泡沫痰是肺泡液體滲出而非分泌物堵塞，抽吸（D）不僅無效且會增加病人焦慮與耗氧。臨床思路應依循『先物理減壓、後藥物治療』的急救邏輯。
Positioning the client in high-Fowler’s with legs dependent is the priority intervention because it uses gravity to reduce venous return (preload), thereby rapidly decreasing pulmonary congestion and improving ventilation. While furosemide is essential for fluid removal, its onset of action takes several minutes, making immediate positional changes the fastest non-invasive measure. Diagnostic tests like chest X-rays do not address the acute respiratory distress, and suctioning is ineffective for alveolar fluid.
在美國 NCLEX 考題中，護理師被預期能獨立執行姿勢調整（Independent nursing action）作為首要處置。在台灣臨床，護理師通常會同步準備氧氣與利尿劑，並同時調整床頭高度，但在國考邏輯中，『不需醫囑且能立即緩解症狀』的動作（如擺位）永遠優先於『需醫囑』的藥物。