— 照護管理 · MEDIUM · MCQ —
護理師照護一位急性胰臟炎病人，病人醫囑為禁食（NPO）、靜脈輸液及止痛藥。下列何項評估發現需要立即關注？
A nurse is caring for a client with acute pancreatitis. The client is prescribed NPO (nothing by mouth) and receives IV fluids and pain medication. Which assessment finding requires immediate attention?
- ASerum amylase level is elevated血清澱粉酶指數升高
- BTemperature 101°F (38.3°C)✓ 正解體溫 101°F (38.3°C)
- CNausea噁心
- DAbdominal distension腹部膨脹
— Explanation · 中文詳解 —
急性胰臟炎是一種強烈的發炎反應。在護理照護中，評估重點在於識別併發症的徵兆。體溫 101°F (38.3°C) 已達發燒標準，這在禁食且接受靜脈輸液的病人身上，極可能暗示著繼發性感染，如胰臟壞死感染、膽道系統發炎或肺炎。這類感染若未及時處理，極易導致敗血症（Sepsis）及多重器官衰竭。腹脹、噁心及澱粉酶升高均為此病的預期病程表現，雖需監測但非立即生命威脅。
Fever in acute pancreatitis suggests a potential infection or progression of inflammation, such as pancreatic necrosis or pneumonia, which can rapidly lead to sepsis. While elevated amylase, nausea, and abdominal distension are expected findings, a temperature of 101°F (38.3°C) requires immediate intervention to prevent life-threatening complications.