# 一位接受化學治療的個案，其絕對嗜中性球計數為 400/mm3。護理師應將哪項指示納入照護計畫中？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397154&lang=zh-tw  
> language: zh-TW  
> subject: Standard/Transmission-Based Precautions/Surgical Asepsis  
> category: SIPC

## 題目

一位接受化學治療的個案，其絕對嗜中性球計數為 400/mm3。護理師應將哪項指示納入照護計畫中？

## 選項

1. 在房間內放置鮮花以改善心情。
2. 在訪客進入房間前，篩檢其是否有疾病。 **✔ 正確答案**
3. 使用肛溫來監測發燒。
4. 鼓勵個案食用生苜蓿芽以補充營養。

**正確答案: 2**

## 解析

嚴重嗜中性球低下需要採取措施以減少接觸感染性微生物，包括篩檢訪客是否有疾病。鮮花、測量肛溫和生苜蓿芽都可能增加感染風險。嗜中性球低下的個案若出現發燒或細微的感染徵象，需要立即處理。

## 深入解析

臨床判斷
運用個案線索、時間點、檢驗數據及安全風險，選擇最適合「嚴重嗜中性球低下防護措施」情境的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶提取。

## 臨床情境

臨床實務指引
針對「嚴重嗜中性球低下防護措施」，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意事項
當完整情境改變了優先順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **嗜中性球低下** — 嗜中性球計數過低，會增加感染風險。
- **絕對嗜中性球計數** — 一種計算出的對抗感染的嗜中性球數量。
- **化學治療** — 用於治療癌症的藥物療法，可能抑制骨髓功能。

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