— 基本照護與舒適 · MEDIUM · MCQ —
一位病人體溫為 103.2°F (39.6°C)。護理師應優先執行何種護理措施？
A client has a temperature of 103.2°F (39.6°C). Which nursing intervention should be prioritized?
- AIncrease fluid intake if not contraindicated✓ 正解若無禁忌症，增加液體攝取
- BBundle the client in extra blankets to sweat it out為病人多加蓋毯子以發汗退燒
- CAdminister an aspirin-based medication to the client給予病人含阿斯匹靈的藥物
- DApply an ice bath to rapidly lower body temperature使用冰水浴快速降低體溫
— Explanation · 中文詳解 —
發燒病人代謝率增加，體液需求量提升，補充足夠水分可預防脫水。冰浴（D）會引發寒顫反而升高體溫；裹厚毯（B）會阻礙散熱；aspirin（C）在某些臨床狀況或特定族群可能禁忌，且給藥需醫囑。優先穩定生命徵象的代謝需求為首要。
Febrile patients have increased metabolic rate and fluid requirements; adequate hydration prevents dehydration. Ice baths (D) can induce shivering and paradoxically raise body temperature; wrapping in heavy blankets (B) impairs heat dissipation; aspirin (C) may be contraindicated in some clinical situations or in certain populations, and requires a physician's order. Stabilizing metabolic demand through vital sign management is therefore the priority.
✦ 台美臨床差異
美國護理師依 protocol 給予退燒藥的權限較大；台灣通常需醫師開立處方後才給予退燒藥。