— 生理適應 · EASY · SATA —
病人接受靜脈輸液時，哪些評估發現應提示護理師可能出現液體容積過多？（選所有適合的）
Which assessment findings should alert the nurse to potential fluid volume excess in a client receiving IV fluids? (Select all that apply.)
- ABounding pulse✓ 正解跳動性強脈搏
- BCrackles on lung auscultation✓ 正解聽診肺部有囉音
- CDecreased blood pressure血壓下降
- DDistended neck veins✓ 正解頸靜脈怒張
- EGeneralized edema✓ 正解全身性水腫
— Explanation · 中文詳解 —
液體容積過多（FVE）導致循環血量增加，產生跳動性脈搏（Bounding pulse）與頸靜脈怒張（JVD）。肺部因液體積聚產生濕囉音（Crackles），並伴隨全身性水腫。低血壓則是容積不足（Hypovolemia）的徵象。
Fluid volume excess presents with signs of circulatory overload, including bounding pulses due to increased blood volume and distended neck veins from venous congestion. Additionally, fluid accumulation in the lungs causes crackles on auscultation, while generalized edema reflects peripheral fluid retention.
✦ 台美臨床差異
臨床上兩地皆以體重與 I/O 作為監測核心，標準一致。