— 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。