— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位剛打上石膏的病人。下列哪項措施最優先？
A nurse is caring for a client with a newly applied plaster cast. Which action is the priority?
- ACover the cast with a blanket to keep it warm用毯子覆蓋石膏以保持溫暖
- BApply a heating pad to the cast to speed drying在石膏上放置熱敷墊以加速乾燥
- CUse fingertips to move the cast while it is drying在石膏乾燥期間用手指尖移動石膏
- DAssess the neurovascular status of the extremity✓ 正解評估肢體的神經血管狀態
— Explanation · 中文詳解 —
剛上石膏的病人，最危險的併發症是艙室症候群（Compartment Syndrome）。護理師必須執行神經血管評估（包含感覺、運動、循環、溫度、膚色）。覆蓋石膏會導致熱量積聚而產生燒傷，使用指尖推動則會壓出凹痕，熱敷墊更是絕對禁止。
The most dangerous complication in a client with a newly applied plaster cast is compartment syndrome. The nurse must perform a neurovascular assessment (including sensation, motor function, circulation, temperature, and color). Covering the cast traps heat and may cause burns; using fingertips creates indentations; and applying a heating pad is absolutely contraindicated.
✦ 台美臨床差異
美台對於石膏護理規範一致，皆強調避免指尖按壓與注意艙室症候群徵象（5P's）。