— 基本照護與舒適 · EASY · MCQ —
病人的體溫為 39°C（102.2°F），護理師應採取哪項行動？
A client has a temperature of 102.2°F (39°C). Which nursing action is indicated?
- AAdminister high-dose antibiotics immediately立即給予高劑量抗生素
- BBundle the client in warm blankets用厚毯包裹病人
- COffer cold ice water to drink提供冰冷開水飲用
- DProvide a tepid sponge bath✓ 正解提供溫水擦浴
— Explanation · 中文詳解 —
發燒時的護理目標是透過物理降溫協助散熱。溫水拭浴（Tepid sponge bath）能利用蒸發（Evaporation）與傳導（Conduction）機轉帶走熱量。必須注意避免過冷的水，以免誘發顫抖（Shivering）。顫抖是身體為產生熱量而進行的肌肉收縮，會導致體溫不降反升，並增加代謝需求與耗氧量，對病人不利。
Provide a tepid sponge bath to facilitate heat loss through evaporation and conduction without causing shivering. Avoid cold water or bundling the client, as these actions can induce shivering, which increases metabolic demand, oxygen consumption, and core body temperature.