— 降低風險 · MEDIUM · MCQ —
護理師照護一位有心衰竭病史的病人。下列哪項發現應優先處理？
A nurse is caring for a client with a history of heart failure. Which clinical finding should the nurse prioritize?
- AMild peripheral edema輕微周邊水腫
- BCrackles in the lung bases✓ 正解肺底部濕囉音
- CWeight gain of 1 lb in a week一週內體重增加 1 磅
- DReports of fatigue主訴疲倦
— Explanation · 中文詳解 —
心衰竭病人肺部出現濕囉音（Crackles）暗示肺水腫，屬嚴重且需立即介入的臨床徵象，代表心輸出量下降導致液體滯留肺部。周邊水腫、疲倦均屬慢性徵狀，體重一週增加 1 lb 在臨床變化上較不具緊急威脅性。
Crackles in the lung bases indicate pulmonary edema, a life-threatening complication of heart failure that requires immediate intervention. While peripheral edema, fatigue, and minor weight gain are common findings, they are less urgent than signs of acute respiratory compromise.
✦ 台美臨床差異
兩地對於心衰竭急性惡化徵兆的監測標準完全一致，強調肺部聽診與體重變化的重要性。