— 生理適應 · MEDIUM · MCQ —
一位肝硬化病人產生腹水，護理師的優先護理措施為何？
A client with cirrhosis develops ascites. Which nursing intervention is priority?
- ARestrict sodium intake限制鈉攝取
- BMonitor daily weights監測每日體重
- CAssess abdominal girth評估腹圍
- DElevate the head of the bed✓ 正解抬高床頭
— Explanation · 中文詳解 —
肝硬化引發腹水（Ascites）時，大量液體聚集在腹腔，會將橫膈膜向上推擠，限制肺部擴張，導致呼吸困難。根據 ABC 原則（Airway, Breathing, Circulation），維持呼吸道通暢與呼吸效率為優先，因此協助病人採取半坐臥姿（High-Fowler's）以減輕對橫膈膜的壓迫最為重要。
Clostridioides difficile spreads via spores that are resistant to alcohol-based hand sanitizers, making contact precautions mandatory. Nurses must wear gowns and gloves upon entry and wash hands with soap and water to effectively remove spores. This strict protocol prevents environmental contamination and cross-infection within the healthcare facility.