護理師照護中性球低下伴隨發燒的病人時,應採取哪些措施?(選所有適合的)
Which of the following actions are appropriate for the nurse to take when caring for a client with a neutropenic fever? (Select all that apply.)
- AMonitor vital signs every 4 hours每4小時監測生命徵象
- BInstitute protective isolation precautions✓ 正解實施保護性隔離措施
- CAdminister prophylactic antibiotics as ordered✓ 正解依醫囑給予預防性抗生素
- DRestrict fresh flowers and potted plants in the room✓ 正解限制房間內擺放鮮花和盆栽
- EPerform rectal temperature checks for accuracy進行直腸體溫測量以確保準確性
中性球低下伴隨發燒屬於腫瘤科急症。防護隔離(Protective isolation)可避免外源性感染。抗生素應儘早投予。鮮花植物因帶有黴菌孢子而禁止。監測生命徵象應更頻繁(如每小時或每兩小時),而非 4 小時。直腸檢查可能造成黏膜破損,引發敗血症,屬於絕對禁忌。
Neutropenia accompanied by fever is an oncologic emergency. Protective isolation prevents exogenous infection. Antibiotics should be administered as early as possible. Fresh flowers and plants are prohibited because they harbor fungal spores. Vital signs should be monitored more frequently (such as every hour or every two hours), not every four hours. Rectal examinations may damage the mucosa and trigger sepsis and are an absolute contraindication.
美台對於中性球低下的隔離防護標準一致,皆嚴格限制侵入性檢查。