— 生理適應 · MEDIUM · SATA —
針對液體容積過載的病人，哪些處置是正確的？（選所有適合的）
Which interventions are appropriate for a client diagnosed with fluid volume overload? (Select all that apply.)
- AAdminister diuretics as ordered✓ 正解依醫囑給予利尿劑
- BMonitor daily weights✓ 正解監測每日體重
- CIncrease sodium intake增加鈉攝取量
- DAssess lung sounds for crackles✓ 正解聽診肺部是否有囉音
- EEncourage fluid intake鼓勵攝取水分
— Explanation · 中文詳解 —
液體容積過載（Fluid volume overload）常見於心衰竭、腎衰竭或過度輸液的病人。臨床表現包括體重增加、周邊水腫、高血壓及肺部囉音（Crackles）。護理重點在於減少體液負荷，包括給予利尿劑、嚴格記錄輸出入量、限制鈉與水分攝取，並每日測量體重以監測液體排除效率。肺部聽診是評估肺水腫有無改善的關鍵。
Appropriate interventions include administering diuretics to promote fluid excretion, monitoring daily weights as the most sensitive indicator of fluid status, and assessing lung sounds for crackles indicating pulmonary edema. Sodium and fluid intake should be restricted, not increased or encouraged.