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一位心臟衰竭的個案出現嚴重端坐呼吸、瀰漫性囉音、粉紅色泡沫痰，且血氧飽和度為 84%。完成優先處置。

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The nurse should recognize ::선택::stable chronic heart failure without congestionisolated anxiety with normal gas exchangeacute cardiogenic pulmonary edema with hypoxemic respiratory distressexpected positional discomfort, first ::선택::sit the client upright, apply prescribed oxygen, begin continuous assessment, and activate urgent helpplace the client flat with the legs elevatedgive a large oral fluid bolusdelay reassessment until after routine morning care, and then ::선택::encourage unrestricted ambulation despite severe hypoxemiawithhold monitoring after the oxygen saturation improves oncefocus only on sleep-hygiene teachingadminister the prescribed IV loop diuretic, prepare ventilatory support if needed, and monitor urine output, renal function, and electrolytes.

護理師應辨識 ::선택::穩定慢性心臟衰竭無充血單純焦慮且氣體交換正常急性心因性肺水腫伴低血氧性呼吸窘迫預期中的姿勢性不適，首先 ::선택::讓個案坐直、依醫囑給氧、開始持續評估，並啟動緊急求助讓個案平躺且雙腿抬高給予大量口服液體延遲再評估直到完成常規晨間照護，然後 ::선택::儘管嚴重低血氧仍鼓勵不受限制的下床活動血氧飽和度改善一次後停止監測僅專注於睡眠衛生衛教給予醫囑靜脈環利尿劑，必要時準備通氣支持，並監測尿量、腎功能與電解質。

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