— 安全與感染控制 · MEDIUM · MCQ —
一位病人體溫達 39.4°C，護理師應採取哪項介入措施？
A client has a temperature of 103°F (39.4°C). Which nursing intervention should be implemented?
- AKeep the patient covered with heavy blankets讓病人蓋上厚毛毯
- BProvide a warm bath to increase comfort提供溫水澡以增加舒適感
- CAdminister cold fluids immediately立即給予冷飲
- DEncourage fluid intake to compensate for insensible loss✓ 正解鼓勵補充水分以補償不顯性失水
— Explanation · 中文詳解 —
高燒會加速代謝與水份流失（如呼吸與排汗增加）。給予充足水分補充是維持電解質平衡的關鍵。冰冷飲品會引發顫抖（shivering）反而升高核心溫度，蓋厚棉被會妨礙散熱，溫水浴需評估，給予水分是目前最安全且必要的措施。
High fever accelerates metabolism and increases insensible fluid loss through respiration and perspiration, making adequate fluid intake essential to maintain electrolyte balance and prevent dehydration. Interventions such as heavy blankets or cold fluids can trigger shivering, which paradoxically raises core temperature, whereas maintaining hydration is the safest and most necessary immediate action.
✦ 台美臨床差異
美台臨床皆視發燒為感染警訊，補水與退燒藥處置皆有標準醫囑。