護理師執行心衰竭病人的入室評估，哪些發現需立即介入？（選所有適合的）
A nurse is performing an admission assessment on a client with a history of heart failure. Which findings require immediate intervention? (Select all that apply.)
- ABilateral crackles in the lung bases✓ 正解雙側肺底濕囉音
- BWeight increase of 3 lbs over the last 24 hours✓ 正解過去 24 小時內體重增加 3 磅
- CReports of nocturia夜尿報告
- DJugular vein distension (JVD)✓ 正解頸靜脈怒張 (JVD)
- EPeripheral pulses 2+周邊脈搏 2+
心衰竭（Heart Failure）病人出現體液過載（Fluid Overload）徵象時，代表心臟輸出量不足以應付代謝需求，導致血液鬱積。肺部濕囉音（Crackles）顯示肺水腫，體重快速增加代表水分滯留，頸靜脈怒張（JVD）則是右心衰竭導致全身靜脈回流受阻的典型表現。護理師需優先處理這些危及呼吸與血流動力學的徵象，以預防急性失代償。
Immediate intervention is required for signs of acute fluid overload and decompensated heart failure, including bilateral crackles indicating pulmonary edema, rapid weight gain suggesting fluid retention, and jugular vein distension reflecting increased central venous pressure. While nocturia and normal peripheral pulses are expected findings in stable heart failure, the presence of crackles, significant weight gain, and JVD signals a potential emergency requiring prompt treatment to prevent respiratory compromise.