— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位發燒病人。哪些護理措施適當？（選所有適合的）
A nurse is caring for a client with a fever. Which nursing actions are appropriate? (Select all that apply.)
- AAdminister antipyretics as ordered✓ 正解依醫囑給予退燒藥
- BKeep clothing and bed linens dry✓ 正解保持衣物與床單乾燥
- CProvide adequate oral fluids✓ 正解提供充足口服液體
- DWrap the client in blankets to induce sweating用毯子包裹個案以誘發出汗
- EMonitor temperature regularly✓ 正解定期監測體溫
— Explanation · 中文詳解 —
發燒是身體對發炎反應的生理防禦機制，護理目標在於提升病人舒適度與控制體溫過高帶來的代謝負擔。適當措施包括使用解熱劑（Antipyretics）以影響下視丘的體溫調節點、保持皮膚與床單乾爽以利散熱及減少不適、提供水分以補充因出汗或呼吸急促流失的體液，並持續監測生命徵象以評估治療效果。反之，用毯子包裹病人旨在人為製造發汗，這會阻礙熱量散發，導致體溫進一步升高，甚至誘發熱衰竭，因此是錯誤的護理行為。
Appropriate nursing interventions for a client with a fever include administering antipyretics to lower the hypothalamic set point, providing adequate fluids to prevent dehydration, keeping clothing and linens dry to promote comfort and heat loss, and monitoring temperature regularly to assess treatment effectiveness. Wrapping the client in blankets to induce sweating is incorrect as it traps heat and can lead to further hyperthermia.