— 生理適應 · EASY · MCQ —
一位心臟衰竭病史的病人出現肺底部濕囉音，下列哪項護理措施最適當？
A nurse is assessing a client with a history of heart failure who has developed crackles in the lung bases. Which nursing intervention is most appropriate?
- AElevate the head of the bed✓ 正解抬高床頭
- BAdminister a beta-blocker給予乙型阻斷劑
- CIncrease the IV fluid rate增加靜脈輸液速率
- DEncourage the client to ambulate鼓勵病人下床活動
— Explanation · 中文詳解 —
心臟衰竭病人出現肺底濕囉音（Crackles），顯示左心室功能受損，液體回流至肺部造成肺水腫（Pulmonary Edema）。護理師的首要行動是降低心臟的前負荷（Preload），透過抬高床頭（High-Fowler's position），利用重力減少靜脈回流至心臟，同時改善橫膈膜運動，減輕呼吸困難。這是非藥物治療中最立即有效的護理措施。
Elevating the head of the bed reduces venous return (preload) and facilitates diaphragm movement, thereby easing the work of breathing in a client with pulmonary edema. This non-pharmacological intervention is the most immediate and effective nursing action to alleviate respiratory distress associated with heart failure exacerbation.