# 一位心衰竭的個案突然變得焦慮，出現囉音、泡沫痰，且血氧飽和度為 84%。護理師應首先採取何項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397147&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位心衰竭的個案突然變得焦慮，出現囉音、泡沫痰，且血氧飽和度為 84%。護理師應首先採取何項行動？

## 選項

1. 測量每日體重。
2. 給予氧氣並將個案置於高坐臥姿勢。 **✔ 正確答案**
3. 鼓勵口服液體以稀釋分泌物。
4. 教導長期控制的鈉限制。

**正確答案: 2**

## 解析

急性肺水腫會威脅氧合作用，因此首要行動是在將個案置於直立姿勢的同時，改善通氣和氧氣輸送。每日體重和鈉衛教對長期管理很重要，但在急性呼吸窘迫期間並非優先事項。口服液體可能加劇體液過荷。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，來選擇最符合急性肺水腫的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的回憶。

## 臨床情境

臨床實務指引
對於急性肺水腫，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **肺水腫** — 肺部積液，損害氣體交換。
- **高坐臥姿勢** — 一種可改善胸腔擴張和呼吸的直立姿勢。
- **血氧飽和度** — 周邊血液中血紅素與氧氣結合程度的測量值。

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