一位 68 歲病人因左腿大規模深部靜脈血栓（DVT）入院。醫囑包含嚴格臥床、抬高左腿、持續 IV 肝素。RN 將早晨照護交派給 UAP。哪項 UAP 行為需 RN 立即介入？
A 68-year-old client is admitted with massive deep vein thrombosis (DVT) in the left leg. Orders include strict bed rest, leg elevation, and continuous IV heparin. The RN delegates morning care to the UAP. Which UAP action requires immediate intervention by the RN?
- AThe UAP uses a soft electric razor to shave the client's facial hair.UAP 使用軟質電動刮鬍刀為病人刮鬍。
- BThe UAP places a pillow under the full length of the left calf to maintain elevation.UAP 將枕頭墊於左小腿全長下方以維持抬高姿勢。
- CThe UAP gently assists the client to turn slightly onto the right side for back care.UAP 輕柔協助病人側轉至右側以進行背部護理。
- DThe UAP massages the swollen, tender left calf with warm lotion to reduce pain.✓ 正解UAP 以溫潤膚油按摩腫脹且觸痛的左小腿以減輕疼痛。
DVT 護理絕對紅線：禁止按摩患肢。按摩會造成血栓脫落（dislodge），形成游離栓子（embolus）順靜脈回流入肺動脈，引發致命的肺栓塞（pulmonary embolism）。 選項 D 是危險錯誤行為，需立即介入制止。 選項 B 抬高全腿正確（避免膕窩壓迫）。 選項 C 翻身與背部護理屬常規 ADL。 選項 A 使用電動刮鬍刀避免出血（IV 肝素病人），是正確安全做法。
DVT absolute contraindication: do not massage the affected leg. Massage can dislodge the thrombus into a pulmonary embolus, causing fatal PE. D is dangerous and requires immediate RN intervention. A: Full-leg elevation is correct (avoids popliteal compression). C: Turning and back care are routine ADLs. D: Electric razor prevents bleeding in a heparinized client—safe.
DVT 照護雙鐵律：「抬高患肢 (Elevation)」、「絕對禁按摩 (No Massage)」。這題巧妙地把護理常規考點融合進 UAP 的任務指派 (Delegation) 情境中，是最高頻出的整合題型。