— 生理適應 · MEDIUM · MCQ —
一位有心衰竭病史的病人反映兩天內體重增加 4 磅。護理師的最佳行動為何？
A client with a history of heart failure reports weight gain of 4 lbs in 2 days. What is the nurse's best action?
- AEncourage the client to increase water intake鼓勵病人增加水分攝取
- BAssess the client for edema and lung sounds✓ 正解評估病人是否有水腫及聽診肺部呼吸音
- CDocument the weight and wait for the next visit記錄體重並等待下次回診
- DTell the client to stop their medication告知病人停止服藥
— Explanation · 中文詳解 —
心衰竭病人體重在兩天內增加 4 磅，這不僅是單純的體重變化，而是急性液體滯留（Fluid retention）的強力指標。護理師必須立即評估病人的液體過多徵象，包括肺部聽診是否有囉音（Pulmonary edema 的早期徵兆）、下肢是否有凹陷性水腫。這是臨床護理的優先行動，旨在確認代償失調的嚴重程度，並及時與醫療團隊溝通調整利尿劑劑量，以防病情惡化至呼吸衰竭。
Rapid weight gain in a client with heart failure is a key indicator of fluid retention and potential acute decompensation. The nurse should immediately assess for signs of fluid overload, such as peripheral edema and crackles in the lungs, to evaluate the severity of the condition and guide timely interventions.