— 降低風險 · MEDIUM · MCQ —
護理師照護一位心衰竭病人，發現兩天內體重增加 5 磅。優先護理動作為何？
A nurse is caring for a client with a history of heart failure who presents with weight gain of 5 lbs over 2 days. What is the priority nursing action?
- AEncourage the client to exercise more鼓勵病人多加運動
- BNotify the provider of weight gain and assessment findings✓ 正解通知醫師體重增加及評估結果
- CIncrease the dose of diuretics增加利尿劑劑量
- DRestrict sodium intake for the next week接下來一週限制鈉攝取
— Explanation · 中文詳解 —
兩天內體重增加 5 磅（約 2.3 公斤）顯示病人出現急性液體滯留，需立即通知醫師（Provider）評估是否調整利尿劑。護理師不能自行增加藥物劑量（那是醫師權責），應回報狀況並準備生命徵象與身體評估（如有無囉音、下肢水腫）供醫師決策。
A weight gain of 5 lbs in two days indicates acute fluid retention, which requires immediate notification of the provider for assessment and potential medication adjustments. The nurse must report these findings promptly but cannot independently increase diuretic dosages, as this is outside the scope of nursing practice.
✦ 台美臨床差異
美台皆強調回報異常體重變化，但在美國依據 Protocol 護理師可能會有更多針對利尿劑調整的建議權。