# 一位個案在戶外工作時倒下，意識混亂、皮膚灼熱，核心體溫為 40.3°C。在啟動緊急救援的同時，護理師應優先採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=497917&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 一位個案在戶外工作時倒下，意識混亂、皮膚灼熱，核心體溫為 40.3°C。在啟動緊急救援的同時，護理師應優先採取哪項行動？ ## 選項 1. 給予口服電解質溶液，並讓個案在溫暖的房間休息 2. 移除多餘衣物，立即以冷水或冰塊開始快速降溫 **✔ 正確答案** 3. 給予 acetaminophen，並在藥效發揮後重新評估體溫 4. 以乾毯覆蓋個案，以減少運送過程中的熱量散失 **正確答案: 2** ## 解析 熱暴露後出現意識混亂合併顯著高體溫，顯示為熱中暑，屬醫療急症。在啟動緊急運送的同時，應立即開始積極快速降溫；不可因等待口服液體或退燒藥而延遲。 ## 深入解析 快速解答 在啟動緊急救援的同時，開始快速積極降溫。意識狀態改變與顯著高體溫可區別熱中暑與單純的熱衰竭。 為什麼這是正確的 熱中暑意味著體溫調節失效，持續上升的核心體溫會迅速傷害腦部、肝臟、腎臟及凝血系統。移除多餘衣物並使用冷水或冰塊降溫，可在安排確定性緊急照護的同時將熱量轉移出去。 簡單比喻或心智圖像 一部危險過熱的引擎必須在等待救援時就開始冷卻，而不是讓它繼續運轉直到檢測或藥物生效。這個比喻說明了急迫性，但無法取代呼吸道支持、監測或安全的臨床降溫程序。 記憶掛鉤 熱暴露加上意識混亂即為熱中暑：立即求救並降溫。 NCLEX 決策規則 當熱傷害包含意識狀態改變或嚴重高體溫時，應視為熱中暑，並在啟動緊急應變的同時開始快速降溫。口服液體僅限於清醒且能安全吞嚥的個案，而退燒藥無法矯正環境性高體溫。 為什麼其他選項是錯的 意識混亂的個案可能吸入（aspirate）口服液體，且溫暖的房間會延遲散熱。Acetaminophen 無法逆轉散熱失敗，而毯子會干擾急需移除熱量的需求。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]OSHA: Heat-Related Illnesses and First AidOccupational Safety and Health Administration ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375157&lang=zh-tw) - [A nurse is caring for a client prescribed Lithium. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375233&lang=zh-tw) - [A nurse is caring for a client prescribed Vancomycin. Which nursing action is most appropr…](https://mymerci.kr/pages/nclex_q.php?qn_id=391734&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=497917&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=497917&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=497917&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=497917&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=497917&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_