— 降低風險 · MEDIUM · MCQ —
對於一位有心衰竭病史的病人，哪項評估發現需要護理師立即注意？
Which assessment finding in a client with a history of heart failure requires the nurse's immediate attention?
- AReports of nocturia主訴夜尿
- BPresence of crackles in the lung bases✓ 正解肺底部出現囉音
- CMild peripheral edema in the ankles腳踝輕微周邊水腫
- DA 2-pound weight gain in 2 days2天內體重增加2磅
— Explanation · 中文詳解 —
心衰竭（Heart failure）病人的優先護理原則是呼吸道與氣體交換。肺部囉音（Crackles）顯示液體過負荷（Fluid overload）已導致肺水腫，這是緊急的臨床指標。相較於體重增加或輕微水腫，肺水腫會直接影響氧氣交換，威脅生命安全，必須立即採取介入措施（如抬高床頭、給氧、給予利尿劑）。
Crackles in the lung bases indicate pulmonary edema, a critical sign of acute fluid overload compromising gas exchange in heart failure. This finding requires immediate intervention over chronic symptoms like mild edema or nocturia to prevent respiratory distress.