— 基本照護與舒適 · MEDIUM · MCQ —
護理師為發燒病人制定照護計畫。優先重點為何？
A nurse is planning care for a client with a fever. What is the priority?
- ASuppressing the immune response抑制免疫反應
- BEncouraging high-intensity exercise鼓勵高強度運動
- CKeeping the client in a very warm room讓病人處於非常溫暖的房間
- DMaintaining fluid intake✓ 正解維持水分攝取
— Explanation · 中文詳解 —
發燒時，身體代謝率會升高（每升高 1°C，代謝率約增加 10-13%），並伴隨呼吸與皮膚散熱導致的水分流失增加。優先維持液體攝取（Fluid intake）是為了預防脫水，並維持正常的循環血量與腎臟功能。這不僅是基礎照護的核心，更是防止發燒併發症（如休克、電解質不平衡）的首要步驟。其他護理措施如降溫藥物、環境調整，均需建立在個案水分充足的基礎上。
Fever increases metabolic rate and insensible water loss through respiration and diaphoresis, placing the client at risk for dehydration. Maintaining fluid intake is the priority to preserve circulatory volume and renal function, which supports thermoregulation and prevents complications like shock. Other interventions, such as antipyretics or environmental cooling, depend on adequate hydration.