— 生理適應 · EASY · MCQ —
護理師照護一位出現呼吸困難和端坐呼吸的心臟衰竭病人。護理師懷疑有體液過多。護理師應首先實施哪項措施？
A nurse is caring for a client with heart failure who is experiencing dyspnea and orthopnea. The nurse suspects fluid overload. Which intervention should the nurse implement first?
- AAdminister a prescribed diuretic給予處方利尿劑
- BRestrict fluid intake限制水分攝取
- CElevate the head of the bed✓ 正解抬高床頭
- DAdminister oxygen給予氧氣
— Explanation · 中文詳解 —
端坐呼吸（Orthopnea）意味著病人需要坐直才能呼吸。將病人的床頭抬高（半坐臥或高坐姿）能利用重力幫助肺部清除積液，減輕呼吸窘迫，是緩解症狀的首要措施。給予利尿劑、限水和給氧也重要，但姿勢調整能立即緩解呼吸困難。
Elevating the head of the bed is the priority intervention for orthopnea as it uses gravity to decrease venous return and facilitate lung expansion, providing immediate respiratory relief. While administering diuretics, restricting fluids, and providing oxygen are essential components of managing fluid overload, positioning offers the fastest symptomatic improvement for dyspnea.
✦ 台美臨床差異
美國護理師常使用生理回饋儀器監測病人的呼吸狀況；台灣病人則多依靠觀察和病人主訴，但床邊監測儀器的普及度正在提高。