護理師協助術後病人第一次下床轉位到椅子。下列何者為優先護理措施?
A nurse is preparing to transfer a client from the bed to a chair for the first time after surgery. What is the priority nursing action?
- APlace a gait belt around the client's waist將步態帶圍繞在病人腰部
- BDangle the client's legs at the bedside讓病人雙腿懸垂於床緣
- CAssess the client's vital signs while supine✓ 正解仰臥時評估病人的生命徵象
- DApply non-skid footwear穿著防滑鞋
術後病人第一次下床轉位,護理師的首要任務是評估病人的生命徵象穩定性,特別是是否存在「姿勢性低血壓(Orthostatic Hypotension)」。手術後的藥物(如麻醉劑、止痛藥)與體液流失,常導致病人站立時出現頭暈或昏厥。在移動病人之前,必須先建立基準生命徵象,並在過程中逐步協助,確保病人安全。
When transferring a postoperative client out of bed for the first time, the nurse's priority task is to assess the stability of the client's vital signs, especially for orthostatic hypotension. Postoperative medications (such as anesthetics and analgesics) and fluid loss often cause dizziness or syncope when the client stands. Before moving the client, baseline vital signs must be established, and assistance should be provided gradually throughout the process to ensure safety.