— 基本照護與舒適 · MEDIUM · SATA —
病人表現出脫水徵象，護理師應採取哪些措施？（選所有適合的）
A client presents with signs of dehydration. Which nursing interventions should be implemented? (Select all that apply.)
- AMonitor daily weights✓ 正解監測每日體重
- BMeasure strict intake and output✓ 正解嚴格記錄出入量
- CAdminister IV fluids as prescribed✓ 正解依醫囑給予靜脈輸液
- DMonitor serum electrolyte levels✓ 正解監測血清電解質水平
- EEncourage high-caffeine beverages鼓勵攝取高咖啡因飲料
— Explanation · 中文詳解 —
脫水（Dehydration）護理的核心在於精確評估液體平衡與恢復灌流。每日體重是最敏感的液體狀態指標，而精確的出入量紀錄（I&O）能反映液體負平衡程度。靜脈輸液（IV fluids）是迅速恢復血管內容量的關鍵，血清電解質監測則能協助判斷脫水伴隨的電解質失衡（如高鈉或低鈉脫水）。針對脫水病人，護理思路應優先確保容量替代，並排除會加重水分流失的因素。
Dehydration care centers on accurate assessment of fluid balance and restoring perfusion. Daily weight is the most sensitive indicator of fluid status, and strict I&O reflects the degree of negative fluid balance. IV fluids rapidly restore intravascular volume, and serum electrolyte monitoring identifies imbalances (such as hyper- or hyponatremic dehydration). Caffeine should be avoided as it worsens fluid loss.