— 照護管理 · HARD · MCQ —
護理師照護一位第四級壓力性損傷的病人，何者為優先行動？
A nurse is caring for a client with a stage 4 pressure injury. Which action is the priority?
- AEnsure the client is repositioned every 2 hours✓ 正解確保每 2 小時為病人翻身
- BConsult the wound care specialist諮詢傷口護理專家
- CComplete a comprehensive nutritional assessment完成全面的營養評估
- DAdminister pain medication as ordered依醫囑給予止痛藥
— Explanation · 中文詳解 —
第四級壓力性損傷（Stage 4 Pressure Injury）涉及肌肉、骨骼或肌腱的暴露，感染風險極高。護理優先順序（Priority）應遵從 ABC 原則與預防惡化。翻身（Repositioning）是移除壓迫源（Pressure relief）的最直接方式，若不移除壓迫，任何傷口治療都無法發揮效用。
A stage 4 pressure injury involves exposed muscle, bone, or tendon and carries a very high risk of infection. Nursing prioritization should follow the ABC principles and focus on preventing further deterioration. Repositioning is the most direct way to relieve the pressure source; without removing the pressure, no wound treatment can be effective.