— 降低風險 · EASY · MCQ —
護理師正在照顧一位有嚴重噁心和嘔吐的病人。下列哪項措施對預防脫水最重要？
A nurse is caring for a client with severe nausea and vomiting. Which intervention is most important to prevent dehydration?
- AProvide oral rehydration solution提供口服補液鹽
- BOffer clear liquids in small, frequent amounts少量多次提供清流質飲食
- CAdminister antiemetic medications as prescribed✓ 正解依醫囑給予止吐藥物
- DMonitor intake and output strictly嚴格監測出入量
— Explanation · 中文詳解 —
面對嚴重噁心嘔吐，護理師應先採取「止吐」措施，從源頭阻斷體液持續喪失。若未先控制嘔吐，即便給予口服補充液，病人也可能因再次嘔吐而無法吸收，反而增加脫水風險。因此，給予止吐藥物（antiemetic medications）是 Priority Action，隨後才進行液體補充與監測。這是臨床處理急性症狀時「解決根本原因」的優先思考順序。
Administering antiemetic medications is the priority intervention because controlling nausea and vomiting directly prevents further fluid loss. While oral rehydration and monitoring are important, they are ineffective if the client continues to vomit. Therefore, stopping the vomiting at its source is the most critical step in preventing dehydration.