— 生理適應 · MEDIUM · SATA —
病人出現體液容積過多症狀，護理師應採取哪些措施？（選所有適合的）
A client presents with symptoms of fluid volume excess. Which interventions should the nurse initiate? (Select all that apply.)
- AElevate the head of the bed✓ 正解抬高床頭
- BAdminister prescribed diuretics✓ 正解給予處方利尿劑
- CMonitor intake and output daily✓ 正解每日監測出入量
- DIncrease sodium intake增加鈉攝取
- EAuscultate lung sounds frequently✓ 正解頻繁聽診肺部呼吸音
— Explanation · 中文詳解 —
體液容積過多（Fluid Volume Excess, FVE）會導致循環負荷過重，進而引發呼吸困難及肺水腫。護理重點在於減輕心臟前負荷、監測液體滯留程度並執行醫囑治療。正確做法包含抬高床頭以改善呼吸舒適度、給予利尿劑排鈉排水、監測出入量以評估治療成效，以及透過聽診肺部確保無肺水腫惡化。鈉鹽攝取應限制以防止水分滯留，而非增加。
Interventions for fluid volume excess include elevating the head of the bed to improve breathing, administering diuretics to promote fluid elimination, and monitoring intake and output to assess balance. Frequent lung auscultation is also essential to detect signs of pulmonary congestion, whereas sodium intake should be restricted to prevent further fluid retention.