— 生理適應 · MEDIUM · SATA —
一位患有慢性腎臟病（CKD）的病人，有體液過載的風險。護理師應監測哪些徵象？（選所有適合的）
A client with chronic kidney disease (CKD) is at risk for fluid overload. Which signs should the nurse monitor for? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BCrackles in the lungs✓ 正解肺部出現捻髮音（濕囉音）
- CWeight loss體重減輕
- DElevated blood pressure✓ 正解血壓升高
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
慢性腎臟病導致腎臟排出水份能力下降，進而引發體液過載。臨床表徵包括心跳強而有力（Bounding pulse）、肺部出現濕囉音（Crackles）、血壓升高（Hypertension）以及周邊水腫。體重減輕通常是脫水或營養不良的指標，非體液過載徵象。
Signs of fluid overload in a client with chronic kidney disease include bounding pulses, elevated blood pressure, peripheral edema, and lung crackles due to increased intravascular volume and pulmonary congestion. Weight loss is not a sign of fluid overload; rather, weight gain is expected due to fluid retention.
✦ 台美臨床差異
美國護理師在監測到這些徵象時，常會依據單位指標調整水份限制；台灣則多需由主治醫師確認後調整。