— 藥理與非經腸給藥 · HARD · MCQ —
對於接受全靜脈營養(TPN)的病人,下列哪項評估發現最令人擔憂?
Which assessment finding is most concerning for a client receiving parenteral nutrition (TPN)?
- ABlood glucose of 250 mg/dL血糖 250 mg/dL
- BUrine output of 50 mL/hr尿量 50 mL/hr
- CCatheter site redness and warmth✓ 正解導管部位紅腫和溫熱
- DWeight gain of 1 kg in 24 hours24 小時內體重增加 1 kg
— Explanation · 中文詳解 —
全靜脈營養(TPN)含有高濃度的葡萄糖、胺基酸與脂肪乳劑,是細菌滋生的絕佳培養基。導管相關血流感染(CRBSI)是 TPN 最嚴重的併發症之一。導管穿刺部位的紅、腫、熱、痛是局部感染的早期徵兆,若不及時處理,細菌極易隨導管進入血液循環,導致敗血症(Sepsis)。在 NCLEX 考試中,處理感染風險與維護導管完整性永遠是護理優先級(Priority)中的最高層級。
Redness and warmth at the catheter site are early signs of infection, which is a critical concern because TPN solutions promote bacterial growth. This finding requires immediate assessment and intervention to prevent progression to catheter-related bloodstream infections or sepsis.