— 降低風險 · HARD · SATA —
護理師為嗜中性白血球減少伴隨發燒的病人規劃照護計畫。應包含哪些措施？（選所有適合的）
A nurse is planning care for a client with a neutropenic fever. Which actions should the nurse include? (Select all that apply.)
- AImplement strict hand hygiene for all staff✓ 正解實施嚴格的手部衛生措施供所有工作人員
- BAllow fresh flowers to improve mood允許鮮花以改善情緒
- CMaintain a low-microbial diet✓ 正解維持低微生物飲食
- DPerform rectal temperature checks執行肛門溫度測量
- ELimit visitors who have respiratory symptoms✓ 正解限制有呼吸道症狀的探視者
— Explanation · 中文詳解 —
嗜中性白血球低下病人免疫功能極弱。必須嚴格洗手以防交叉感染；飲食應避免生食（低微生物飲食）；限制有症狀的訪客接觸。選項 B 錯誤：鮮花泥土中有黴菌與細菌。選項 D 錯誤：直腸體溫測量會導致黏膜損傷，增加細菌侵入血液循環的風險。
Strict hand hygiene is essential to prevent infection transmission in immunocompromised neutropenic clients. Care should also include maintaining a low-microbial diet to reduce pathogen ingestion and limiting visitors with respiratory symptoms to minimize exposure to infectious agents.
✦ 台美臨床差異
美國醫院對於嗜中性白血球低下的隔離防護層級非常嚴格，台灣亦同，但針對飲食限制的定義略有差異。