— 生理適應 · EASY · MCQ —
護理師教導心衰竭病人監測液體平衡，哪項徵象應告知回報？
A nurse is teaching a client with heart failure how to monitor fluid balance. Which sign should the nurse instruct the client to report?
- AWeight gain of 3 lbs in 2 days✓ 正解2天內體重增加3磅
- BClear urine尿液清澈
- CIncreased energy level體力增加
- DImproved sleep quality睡眠品質改善
— Explanation · 中文詳解 —
心衰竭病人體內的水分滯留是病情惡化的重要警訊。體重變化是評估液體負荷最敏感且有效的指標，因為水分滯留往往在臨床症狀（如肺囉音、水腫）出現前就會反應在體重上。一般建議病人每天在相同時間、穿著相同衣物並排空膀胱後秤重。若出現 2 天內增加 3 磅或 1 週內增加 5 磅以上，通常代表水分過度滯留，需調整利尿劑劑量或立即就醫，以防急性肺水腫發生。
A weight gain of 3 pounds in two days is a sensitive indicator of fluid retention and potential fluid overload in clients with heart failure. Clients should be instructed to report such rapid increases, as they often precede clinical symptoms like edema or pulmonary congestion and may require immediate medical intervention.
✦ 台美臨床差異
台美臨床對於「每日秤重」的衛教一致。美國醫院護理常規通常會將此作為心衰竭教育的核心內容，並要求病人記錄於日記中。