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照護管理 · EASY · MCQ

護理師被分配照顧四名化療病患。完成查房後,護理師必須優先評估與處置哪位病患以防致死結果?

An oncology nurse is assigned to care for four clients experiencing various complications from chemotherapy. Upon completing initial rounds, which client must the nurse evaluate and manage first to prevent a potentially rapid fatal outcome?

  • AA client displaying scattered distinct tiny red petechiae on their lower calves.
    雙小腿出現散在的微小紅色瘀點的病人。
  • BA client reporting excruciating burning pain directly associated with severe oral mucositis.
    主訴嚴重口腔黏膜炎直接相關的劇烈灼痛感的病人。
  • CA profoundly nauseous client who just forcefully vomited 300 mL of dark green bile.
    嚴重噁心,剛用力嘔吐出 300 mL 深綠色膽汁的病人。
  • DA client with an absolute neutrophil count (ANC) of 400/mm³ registering a sudden temperature of 38.3°C (101°F).✓ 正解
    絕對嗜中性白血球計數 (ANC) 為 400/mm³ 且突然體溫升至 38.3°C (101°F) 的病人。
Explanation · 中文詳解

本題強化腫瘤急症 (Febrile Neutropenia)。當 ANC < 500 時,病患失去免疫軍隊。只要伴隨 >38度C 發燒,代表病菌正在血中不受控地繁殖,兩小時內必引發敗血休克。第一時間必須打上廣效抗生素。

This question emphasizes oncologic emergency (febrile neutropenia). When ANC <500, the client lacks immune defenses. Fever >38°C indicates uncontrolled bacterial proliferation in the bloodstream, leading to septic shock within hours. Immediate broad-spectrum IV antibiotics are required.

✦ 台美臨床差異

ANC低+發燒=Sepsis。全球腫瘤病房頭號殺手。

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