— 生理適應 · EASY · SATA —
接受靜脈輸液的病人，下列哪些是液體容積負荷過重的徵象？（選所有適合的）
Which of the following findings are signs of fluid volume overload in a patient receiving IV therapy? (Select all that apply.)
- ACrackles upon auscultation of the lungs✓ 正解聽診肺部時發現捻发音
- BDistended neck veins (JVD)✓ 正解頸靜脈怒張 (JVD)
- CDecreased blood pressure血壓下降
- DBounding pulse✓ 正解脈搏強而有力
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
液體過量導致血管內壓力升高，臨床表現為肺部濕囉音（水分滲入肺泡）、頸靜脈怒張、脈搏強而有力（Bounding pulse）以及因靜水壓升高導致的周邊水腫。血壓通常會升高而非降低，除非病人已進入嚴重的循環衰竭階段。
Fluid volume overload increases intravascular pressure, leading to pulmonary crackles from alveolar fluid, jugular vein distention, bounding pulses due to increased cardiac output, and peripheral edema from fluid extravasation. Blood pressure typically rises rather than falls unless severe circulatory failure occurs.
✦ 台美臨床差異
台美護理評估標準一致，皆將聽診呼吸音與觀察 JVD 列為輸液照護的核心評估。