— 基本照護與舒適 · MEDIUM · SATA —
一位有體液容積不足風險的病人，護理師應包含哪些措施？（選所有適合的）
A client is at risk for fluid volume deficit. Which interventions should the nurse include? (Select all that apply.)
- AMonitor strict intake and output (I&O)✓ 正解嚴格監測出入量（I&O）
- BAssess skin turgor and mucous membranes✓ 正解評估皮膚彈性和黏膜狀況
- CAdminister IV fluids as ordered✓ 正解依醫囑給予靜脈輸液
- DEncourage fluid intake if not contraindicated✓ 正解若無禁忌症，鼓勵病人攝取水分
- ELimit all physical activity to save energy限制所有體力活動以保存能量
— Explanation · 中文詳解 —
體液容積不足（Fluid volume deficit）的護理重點在於『監測、補充與評估』。護理師需嚴格記錄進出量（I&O）以判斷平衡狀況，評估脫水指標（皮膚彈性、黏膜乾燥），並配合醫囑給予液體補充。鼓勵適度飲水是維持體液平衡的重要行為。限制體力活動並非預防脫水的直接手段，適度活動反而對代謝循環有益。
To manage fluid volume deficit, the nurse should monitor strict intake and output, assess for signs of dehydration such as poor skin turgor and dry mucous membranes, and administer IV fluids as prescribed. Encouraging oral fluid intake is also appropriate if the client can swallow safely, whereas restricting activity does not directly address fluid balance.