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降低風險 · MEDIUM · SATA

護理師準備協助病人進行腰椎穿刺。應採取哪些措施?(選所有適合的)

A nurse is preparing a client for a lumbar puncture. Which actions should the nurse perform? (Select all that apply.)

  • AInstruct the client to empty their bladder✓ 正解
    指示病人排空膀胱
  • BPosition the client in a lateral recumbent position with knees drawn up✓ 正解
    將病人置於側臥屈膝姿勢
  • CEnsure the informed consent is signed✓ 正解
    確認知情同意書已簽署
  • DVerify that the patient has been NPO for 8 hours
    確認病人已禁食 8 小時
  • ELabel all specimen tubes accurately✓ 正解
    準確標示所有檢體管
Explanation · 中文詳解

腰椎穿刺(Lumbar puncture)是一項侵入性檢查,護理師的準備工作重點在於預防醫源性傷害、確保程序合法性及檢體正確性。術前排空膀胱可避免穿刺時壓力改變導致膀胱受損;側臥屈膝姿勢能將脊椎間隙擴張至最大,便於穿刺;確認同意書是法律保障;正確標示檢體則能確保診斷結果的準確性。該檢查不涉及腸胃道,因此無需禁食。

Lumbar puncture is an invasive procedure, and nursing preparation focuses on preventing iatrogenic injury, ensuring legal validity, and ensuring correct specimen handling. Emptying the bladder beforehand prevents bladder injury related to pressure changes during the procedure; the lateral recumbent position with knees drawn up maximizes the intervertebral spaces and facilitates needle insertion; verifying informed consent provides legal protection; accurate specimen labeling ensures diagnostic accuracy. This procedure does not involve the gastrointestinal tract, so fasting is not required.

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