— 照護管理 · HARD · MCQ —
護理師評估禁食病人照護計畫，哪項行動最優先？
A nurse is reviewing the plan of care for a client who is NPO. Which action should be prioritized?
- AUpdate the patient's family on the treatment plan向患者家屬更新治療計畫
- BSchedule the physical therapy session for the morning安排上午的物理治療課程
- CPerform oral care to manage dryness進行口腔護理以緩解乾燥
- DEnsure IV access is patent for fluid replacement✓ 正解確保靜脈通路暢通以進行液體補充
— Explanation · 中文詳解 —
NPO 病人無法由口補充水分與電解質，維護靜脈路徑（IV access）以供應輸液（Fluid replacement）是維持代謝恆定的核心，屬於 ABC 中的循環保護。口腔護理、物理治療與家屬溝通均重要，但優先權皆次於維持體液平衡的生理需求。
For a client who is NPO, maintaining fluid and electrolyte balance is the highest priority to ensure circulatory stability. While oral care, physical therapy, and family communication are important aspects of holistic care, they do not take precedence over the physiological need for hydration and metabolic homeostasis.
✦ 台美臨床差異
美醫院較依賴醫囑系統自動提醒 IV 維護；台灣護理師常需手動監測輸液滴速與留置針狀態。