# 一位慢性收縮性心衰竭個案出現嚴重呼吸困難、粉紅色泡沫痰、血壓 168/98、心跳 124、室內空氣下血氧飽和度 84%、雙側肺中野有囉音。護理師應預期哪些處置？請選出所有適當選項。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375089&lang=zh-tw  
> language: zh-TW  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## 題目

一位慢性收縮性心衰竭個案出現嚴重呼吸困難、粉紅色泡沫痰、血壓 168/98、心跳 124、室內空氣下血氧飽和度 84%、雙側肺中野有囉音。護理師應預期哪些處置？請選出所有適當選項。

1

針對低氧與呼吸努力啟動NIV(BiPAP)

2

若血壓允許,給IV nitroglycerin降前後負荷

3

依醫囑給予IV furosemide以排除體液

4

以雙腿下垂之高Fowler位降低前負荷

5

給NS 1 L快速注射以支持心輸出

## 解析

急性心因性肺水腫治療：採高坐臥姿且雙腳下垂可減少前負荷；非侵襲性正壓呼吸（BiPAP/CPAP）可改善氧合及降低插管率；靜脈注射環利尿劑以移除過多體液；靜脈注射硝化甘油可降低前負荷及後負荷，尤其對高血壓有幫助。嗎啡目前僅選擇性使用（因擔心增加死亡率）。生理食鹽水推注是禁忌的——會加劇體液容積過量。強心藥物保留用於伴隨低血壓之心因性休克。

## 深入解析

LMNOP:Lasix、Morphine(選擇性)、Nitrate、O2/NIV、Position直立。注意心因性休克 — 可能需強心劑與機械輔助。

## 臨床情境

清醒但焦慮。心臟超音波EF 25%。末次迴圈利尿劑12小時前。無插管病史。

## 重要概念

- **心因性肺水腫** — 左心壓力升高致肺鬱血。
- **NIV** — 非侵入性正壓通氣 — 面罩CPAP或BiPAP。
- **前負荷** — 心室舒張末期容積 — 直立、利尿、nitrate可降低。

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