# 一位正在接受 25% 白蛋白的病人出現呼吸困難、頸靜脈怒張、高血壓和囉音。護理師應採取何種措施？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=522668&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## 題目 一位正在接受 25% 白蛋白的病人出現呼吸困難、頸靜脈怒張、高血壓和囉音。護理師應採取何種措施？ ## 選項 1. 增加輸注速率，因為囉音表示膠體滲透壓低。 2. 停止白蛋白輸注，並立即進行體液和心肺再評估。 **✔ 正確答案** 3. 用無菌水稀釋剩餘的白蛋白並繼續輸注。 4. 將這些發現記錄為預期情況，並在整瓶輸注完畢後再評估。 **正確答案: 2** ## 解析 在濃縮白蛋白治療期間，呼吸困難、頸靜脈怒張、高血壓和囉音表示高血容量或肺水腫。應立即停止輸注並重新評估。 ## 深入解析 快速解答 將 白蛋白輸注期間新出現的心肺充血視為輸注相關的體液過量。 為何這是正確的 濃縮白蛋白會擴張血管內容量。繼續或加速輸注會加重肺水腫，而無菌水稀釋可能導致溶血。 簡單類比或心像 將每次輸注視為受控的臨床系統：核實產品和通路、識別變化的跡象、停止可預防的暴露、穩定病人並確認反應。 記憶點 產品、通路、相容性、輸注跡象、保護措施和再評估。 NCLEX 決策規則 選擇能預防最直接輸注相關傷害的措施，同時保留血管通路和醫囑診斷證據。 為何其他選項是錯誤的 重新啟動可疑產品、繞過安全裝置、強行疏通阻塞導管或延遲再評估的選項，可能將可逆的警訊轉變為嚴重傷害。References 1DailyMed: Albumin (Human) 25%Hypervolemia and pulmonary edema warnings, infusion interruption, hemodynamic reassessment, and dilution precautions ## 臨床情境 血液製品、營養和靜脈輸液安全審查 核實產品、處方、途徑、通路裝置、過濾器或管路、相容性、基準發現、新出現的不良跡象、應對計畫和可衡量的追蹤。 ## 相同主題題目 - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=522668&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=522668&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=522668&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=522668&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=522668&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_