— 降低風險 · HARD · SATA —
護理師在照護一位白血球低下並伴隨發燒的病人時，應採取哪些措施？（選所有適合的）
Which of the following actions should a nurse take when caring for a client with a neutropenic fever? (Select all that apply.)
- AImplement strict hand hygiene for all visitors✓ 正解對所有訪客實施嚴格的洗手衛生
- BProvide fresh fruits and vegetables to increase immunity提供新鮮水果和蔬菜以增加免疫力
- CInitiate reverse isolation precautions✓ 正解啟動逆向隔離防護措施
- DAvoid rectal temperatures or suppositories✓ 正解避免測量肛門溫度或使用栓劑
- EAssess for signs of infection every 4 hours✓ 正解每4小時評估感染徵象
— Explanation · 中文詳解 —
白血球低下病人免疫功能極弱，需採取保護性隔離（Reverse isolation）。絕對禁止直腸侵入性操作（包括體溫、栓劑、灌腸），以防腸道細菌進入血液造成敗血症。新鮮蔬果因帶菌風險須避免。嚴格手部衛生與頻繁感染跡象評估是核心防禦手段。
Strict hand hygiene and reverse isolation precautions are critical to protect neutropenic clients from exogenous pathogens. Rectal procedures must be avoided to prevent mucosal trauma and subsequent bacteremia. Frequent assessment for infection signs is necessary, while fresh fruits and vegetables should be restricted due to potential microbial contamination.
✦ 台美臨床差異
美國在腫瘤中心多使用更嚴格的防護標準，台灣臨床對於護理師主動進行保護性隔離的執行彈性較大，但在大型醫院皆有標準化流程。