還有更多這樣的題目挑戰 ›

檢視變化中的水疱皮疹型態，並判斷感染管制措施應如何調整。

Trend

選擇作答後，查看答案。

Time	Data
Admission	Afebrile; grouped vesicles are confined to the right T8 dermatome and can be fully covered; no lesions elsewhere.無發燒；群聚性水疱侷限於右側 T8 皮節，可完全覆蓋；其他部位無病灶。
Hospital day 2, 0800	Temperature 38.2°C; new vesicles are present on the left forearm and scalp outside the original dermatome.體溫 38.2°C；左前臂及頭皮在原發皮節之外出現新水疱。
Hospital day 2, 1000	Additional scattered vesicles appear on the trunk and left thigh; one unprotected staff entry occurred before the spread was recognized.軀幹及左大腿出現更多散在性水疱；在發現擴散前，曾有一名工作人員未穿戴防護裝備進入病房。

Q1. How should the nurse interpret the change?護理師應如何解讀此變化？

Possible disseminated herpes zoster可能為瀰漫性帶狀疱疹 Expected healing of localized zoster局部性帶狀疱疹預期癒合中 Allergic contact dermatitis過敏性接觸性皮膚炎 Localized bacterial cellulitis局部性細菌性蜂窩性組織炎

Q2. Which infection-control response is the priority?哪一項感染管制措施為最優先？

Continue lesion coverage without changing room placement繼續覆蓋病灶，不改變病房安排 Initiate Airborne plus Contact Precautions and arrange AIIR placement啟動空氣傳染及接觸防護措施，並安排空氣傳染隔離病房 Use Droplet Precautions only僅採取飛沫防護措施 Delay isolation until the viral test returns等待病毒檢驗結果再進行隔離

Q3. What additional action is appropriate?哪一項額外措施是適當的？

Leave the room door open for observation打開房門以便觀察 Encourage routine hallway ambulation鼓勵例行在走廊走動 Notify infection prevention and identify susceptible exposures通知感染管制部門並找出易感暴露者 Remove all coverings from draining lesions移除所有覆蓋滲液病灶的敷料

查看答案

相同主題的下一題A nurse is caring for a client newly admitted with suspected methicillin-resistant Staphyl…本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。