— 生理適應 · MEDIUM · MCQ —
護理師照護一位心衰竭病人，該病人突然發生呼吸困難。優先行動為何？
A nurse is caring for a client with a history of heart failure who is suddenly short of breath. What is the priority action?
- AAdminister diuretics給予利尿劑
- BNotify the physician通知醫師
- CObtain an EKG取得心電圖
- DPlace in high-Fowler's position✓ 正解採高福勒氏體位
— Explanation · 中文詳解 —
心衰竭（Heart failure）病人突發呼吸困難（Dyspnea），通常是因為肺部充血或急性肺水腫（Pulmonary edema）。在此緊急情況下，首要護理行動是將病人置於高頭位（High-Fowler's position）。此擺位能利用重力減少靜脈回流，減輕心臟前負荷（Preload），同時有助於橫膈膜下移，增加肺部擴張空間，從而立即改善呼吸窘迫感。這是護理師在醫師介入前，能最快執行的有效緩解措施。
Placing a client with heart failure in a high-Fowler's position is the priority action because it uses gravity to reduce venous return (preload) and allows for better lung expansion. This immediate intervention helps alleviate dyspnea caused by pulmonary congestion before other treatments are administered.