심화 해설
Clinical Judgment
This question assesses your ability to apply the principles of prioritization and the ABCs (basic physiological needs). The patient is at high risk for dehydration due to high fever and severe symptoms. High fever increases metabolic rate and insensible fluid loss, while fatigue and discomfort reduce oral intake. Therefore, encouraging increased fluid intake and monitoring for signs of dehydration is the most important intervention. This is fundamental nursing care that maintains the fluid and electrolyte balance essential for sustaining life, prevents complications, and aids recovery.
Memory Tip
Flu + Fever = Fluids First!
KR vs US
In Korea, prescribing and administering antipyretics for influenza patients is very common, but the NCLEX/NGN prioritizes meeting basic physiological needs (fluids, rest) and safety (especially the risk of Reye syndrome) over medication administration. Also, while infection control (isolation, handwashing) is important in US nursing, in this case, the patient's direct physiological instability (risk of dehydration) is considered the more urgent issue.
임상 시나리오
Clinical Practice Guide
When caring for patients with influenza A, prioritize fluid intake, and electrolyte drinks may be recommended. Regularly assess vital signs, especially heart rate and blood pressure, and accurately record intake and output (I&O). Evaluate skin turgor, oral mucosa condition, and the degree of sunken eyes to determine the level of dehydration.
Caution
Option 1 (administering aspirin) is a trap. Administering aspirin to children and adolescents with influenza or chickenpox symptoms carries the risk of a fatal complication called Reye syndrome. It is often not recommended for adults either, and administering medication for fever/pain relief is a lower priority than basic interventions such as fluid intake.
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.