— 基本照護與舒適 · MEDIUM · SATA —
病人有體液容積缺失的風險，護理師應包含哪些護理計畫？（選所有適合的）
A client is at risk for fluid volume deficit. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AMonitor strict intake and output✓ 正解嚴格監測進出水量
- BWeigh the client daily✓ 正解每日稱量病人體重
- CEncourage fluid intake as tolerated✓ 正解在耐受範圍內鼓勵補充水分
- DMonitor for skin turgor✓ 正解監測皮膚彈性
- EAdminister IV fluids as ordered✓ 正解依醫囑給予靜脈輸液
— Explanation · 中文詳解 —
體液容積缺失風險的護理核心在於精確監測體液平衡、維持循環穩定與早期發現脫水徵兆。護理師需透過客觀數據（體重、I/O）與身體評估（皮膚彈性）來評估病人的體液狀態。對於具備吞嚥能力的病人，鼓勵攝取水分是預防脫水的首要措施，若情況嚴重或無法口服，則需依醫囑給予靜脈輸液（IV Fluids）。這些措施皆能有效監測與維持病人的體液平衡，降低併發症風險。
Assessment is the first step of the nursing process; therefore, the nurse must evaluate the pain's intensity and characteristics before intervening. This ensures that treatments are appropriate and do not mask signs of serious underlying conditions.