— 降低風險 · MEDIUM · SATA —
護理師評估病人是否有體液過量徵象。下列哪些發現是預期中的？（選所有適合的）
A nurse is assessing a client for signs of fluid volume overload. Which findings should the nurse expect? (Select all that apply.)
- ADistended neck veins✓ 正解頸靜脈擴張
- BBounding pulse✓ 正解脈搏強而有力
- CCrackles in the lungs✓ 正解肺部濕囉音
- DIncreased hemoglobin levels血紅素濃度增加
- EWeight gain✓ 正解體重增加
— Explanation · 中文詳解 —
體液過量（Hypervolemia）會導致血管內壓力增加。頸靜脈怒張反映右心房壓力上升，跳躍式脈搏代表血管內容積過多，肺部濕囉音顯示液體滲漏至肺泡。體重增加是水分滯留的敏感指標。血紅素通常會因稀釋效應而下降，而非上升。
Fluid volume overload leads to increased venous pressure, causing distended neck veins, and excess blood volume results in a bounding pulse. Pulmonary congestion from fluid accumulation produces crackles, while rapid weight gain is a sensitive indicator of fluid retention. Hemoglobin levels typically decrease due to hemodilution rather than increase.
✦ 台美臨床差異
美國護理師常執行床邊超音波評估下腔靜脈，台灣則多仰賴身體檢查如頸靜脈與聽診。