— 生理適應 · EASY · MCQ —
一位病患出現體液負荷過重徵象，護理師應優先關注哪項發現？
A client presents with signs of fluid volume overload. Which finding should the nurse prioritize?
- AFull, bounding pulses強而有力、幅度大的脈搏
- BCrackles upon lung auscultation✓ 正解聽診肺部時出現囉音
- C1+ pitting edema in ankles踝部有 1+ 凹陷性水腫
- DIncreased blood pressure血壓升高
— Explanation · 中文詳解 —
體液負荷過重（Fluid volume overload）會導致血管內液體壓力升高，進而滲透至肺間質與肺泡，引發肺水腫。肺部出現囉音（Crackles）是液體進入肺泡的臨床指標，代表呼吸功能受損，這是最危急的生命徵象，需優先處理（ABC 原則：Airway, Breathing, Circulation）。
Crackles upon lung auscultation should be prioritized as they indicate pulmonary edema, which poses an immediate threat to airway patency and gas exchange. While bounding pulses, edema, and hypertension are signs of fluid overload, respiratory compromise takes precedence according to ABC (Airway, Breathing, Circulation) principles.