— 基本照護與舒適 · EASY · MCQ —
護理師照護一位長期臥床的病人，下列哪項措施對於預防壓瘡最有效？
A nurse is caring for a client who is immobile. Which action is most effective in preventing pressure injuries?
- AMaintaining a high-Fowler’s position維持高半坐臥位
- BMassaging reddened bony prominences按摩發紅的骨突處
- CApplying powder to keep the skin dry塗抹粉末以保持皮膚乾燥
- DRepositioning the client every 2 hours✓ 正解每2小時為病人翻身
— Explanation · 中文詳解 —
預防壓瘡的黃金準則是定時翻身（每兩小時一次）以解除受壓部位的組織缺氧。按摩骨突處反而會導致皮下組織受損，增加壓瘡風險。保持皮膚乾燥是正確的，但灑粉可能會結塊摩擦皮膚。高半坐臥位會增加剪力與摩擦力，需避免長時間維持。
The gold standard for preventing pressure injuries is scheduled repositioning every two hours to relieve tissue hypoxia at pressure points. Massaging bony prominences actually damages subcutaneous tissue and increases the risk of pressure injuries. Keeping the skin dry is correct, but applying powder can cake and cause friction on the skin. Maintaining a high-Fowler's position increases shear and friction forces and should not be maintained for long periods.
✦ 台美臨床差異
美國護理師常使用特定壓瘡評估量表（如 Braden Scale）強制要求翻身頻率；台灣臨床較依賴護理師經驗與家屬協助。