— 降低風險 · MEDIUM · SATA —
護理師為一位嗜中性白血球減少並發燒的病人制定護理計畫，應包含哪些措施？（多選）
A nurse is planning care for a client with a neutropenic fever. Which of the following interventions should the nurse include? (Select all that apply.)
- AInitiate protective environment precautions✓ 正解啟動保護性環境隔離措施
- BAdminister prophylactic antibiotics as ordered✓ 正解依醫囑給予預防性抗生素
- CAllow fresh fruit and vegetables in the diet允許飲食中包含新鮮水果和蔬菜
- DMonitor temperature every 4 hours✓ 正解每4小時監測體溫
- ERestrict visitors with active infections✓ 正解限制患有活動性感染之探視者進入
— Explanation · 中文詳解 —
嗜中性白血球減少症病人免疫力極低，需採取保護性隔離（A）、限制感染源接觸（E）、密切監測體溫以早期偵測敗血症（D）、依醫囑給予抗生素（B）。C 選項中生鮮蔬果易帶有細菌，免疫抑制病人應避免食用，需煮熟。
Clients with neutropenia have extremely low immunity and require protective isolation (A), restriction of exposure to sources of infection (E), close monitoring of temperature for early detection of sepsis (D), and administration of antibiotics as ordered (B). Option C is incorrect because fresh fruits and vegetables may carry bacteria; immunosuppressed clients should avoid raw produce and should consume thoroughly cooked food.
✦ 台美臨床差異
美國護理師常執行床邊床旁環境評估，台灣則高度依賴感染控制室規範與隔離標示。