— 生理適應 · MEDIUM · SATA —
管理心臟衰竭病患以預防液體過載，哪些措施適當？（選所有適合的）
Which interventions are appropriate for managing a client with heart failure to prevent fluid overload? (Select all that apply.)
- AAdminister diuretics as prescribed✓ 正解依醫囑給予利尿劑
- BMonitor daily weights✓ 正解監測每日體重
- CEncourage a low-sodium diet✓ 正解鼓勵低鈉飲食
- DIncrease fluid intake to flush the kidneys增加水分攝取以沖洗腎臟
- EMonitor intake and output✓ 正解監測出入量
— Explanation · 中文詳解 —
心衰竭病患的核心照護在於減少前負荷。利尿劑 (A) 可排出過多液體；每日體重 (B) 是監測水份滯留最敏感指標；限鈉 (C) 可減少水份蓄積；測量出入量 (E) 是精確監測液體平衡的手段。D 選項錯誤，增加攝取量會加重水腫與心臟壓力。
To manage heart failure and prevent fluid overload, nurses should administer prescribed diuretics to eliminate excess fluid, monitor daily weights as the most sensitive indicator of fluid retention, and encourage a low-sodium diet to reduce water accumulation. Additionally, accurate intake and output monitoring is essential for assessing fluid balance, whereas increasing fluid intake would exacerbate the condition.
✦ 台美臨床差異
美國護理指導會包含非常詳細的飲水份量與鹽分標示閱讀；台灣同樣重視，但在結構性出院衛教上仍有改進空間。