— 生理適應 · MEDIUM · SATA —
一名心衰竭病史的個案，兩天內體重增加 5 磅，出現呼吸困難與下肢水腫。護理師應優先執行哪些措施？（選所有適合的）
A nurse is caring for a client with a history of heart failure who presents with weight gain of 5 lbs in two days, dyspnea, and bilateral pitting edema. Which nursing interventions should be prioritized? (Select all that apply.)
- AAdminister prescribed intravenous loop diuretics✓ 正解給予處方之靜脈注射環狀利尿劑
- BMonitor strict intake and output every shift✓ 正解每班次嚴格監測出入量
- CIncrease dietary protein to prevent skin breakdown增加膳食蛋白質以預防皮膚破損
- DAssess breath sounds for crackles✓ 正解評估肺部囉音
- EPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
— Explanation · 中文詳解 —
心衰竭病患出現體重快速增加與呼吸困難，顯示液體過負荷（Fluid Overload）。治療重點為排出多餘水分（給予利尿劑）、評估液體進出量、監測肺部聽診有無囉音（肺水腫指標），以及透過高頭位減輕心臟負擔與緩解呼吸困難。蛋白質攝取與水腫處置無直接即時關係。
Sharing drinking glasses increases infection risk by transmitting pathogens through saliva, while using the same towel for hands and face can transfer microorganisms from contaminated surfaces to mucous membranes. These practices facilitate the spread of respiratory and other infections within the household environment.
✦ 台美臨床差異
美國強調給藥節奏，台灣護理師執行醫囑給藥後，常需更積極協助翻身與壓瘡評估。