— 降低風險 · MEDIUM · MCQ —
護理師正在照顧一位剛置入周邊靜脈輸液管的病人。下列哪項評估發現需要立即通知醫療提供者？
A nurse is caring for a client with a newly inserted peripheral IV line. Which assessment finding requires immediate notification of the healthcare provider?
- AThe client has a sudden onset of fever and chills✓ 正解病人突然出現發燒和畏寒
- BThe insertion site is slightly red and warm to touch置管部位輕微紅腫且觸摸時發熱
- CThe client reports mild discomfort at the insertion site病人報告置管部位有輕微不適
- DThe IV fluid is infusing at the prescribed rate靜脈輸液正按處方速率輸注
— Explanation · 中文詳解 —
周邊靜脈導管（Peripheral IV）雖然是常見的護理處置，但若發生感染或輸液反應，可能迅速發展為全身性敗血症。發燒和畏寒是全身性感染的典型徵兆。若病人出現這些症狀，代表可能存在導管相關血流感染（CRBSI）或輸液污染，這是嚴重的醫療安全事件，護理師必須立即通知醫師進行評估，並可能需要移除導管。
Although peripheral IV catheters are routine, infections or infusion reactions can rapidly progress to systemic sepsis. Fever and chills are classic signs of systemic infection. If a client develops these symptoms, catheter-related bloodstream infection (CRBSI) or infusion contamination may be present—this is a serious safety event requiring immediate physician notification and possible catheter removal.