— 基本照護與舒適 · EASY · MCQ —
一位病人發燒至 102.4°F（約 39.1°C）。護理師應先執行何項措施？
A nurse is caring for a client with a fever of 102.4°F. Which measure should be taken first?
- AAssess the client's vital signs and clinical status✓ 正解評估病人的生命徵象與臨床狀況
- BApply cold ice packs to the entire body在全身敷上冰塊
- CNotify the physician to order blood cultures通知醫師開立血液培養檢查
- DImmediately administer an antipyretic medication立即給予退燒藥物
— Explanation · 中文詳解 —
護理原則首重評估（Assessment）。在處理發燒前，必須先評估病人的生命徵象、精神狀態與發燒成因，確認是否為敗血症風險。未經評估直接給藥或冷敷可能掩蓋病情，且冰敷可能導致病人寒顫，反而增加代謝熱量。
Assessment is the first step in the nursing process; therefore, the nurse must evaluate vital signs and clinical status to determine the cause and severity of the fever before intervening. Immediate cooling or medication without assessment may mask symptoms or cause adverse effects like shivering.
✦ 台美臨床差異
美國護理師常依據 Protocol 自行評估是否使用退燒藥；台灣則嚴格遵守醫師處方，護理師需確認醫囑再給藥。