— 降低風險 · MEDIUM · MCQ —
護理師協助病人進行腰椎穿刺。下列哪項措施對預防過程中受傷至關重要？
A nurse is preparing a client for a lumbar puncture. Which action is essential to prevent injury during the procedure?
- AAssisting the client into a side-lying, fetal position✓ 正解協助病人採取側臥屈膝姿勢
- BEncouraging the client to talk during the procedure鼓勵病人在過程中說話
- CAdministering sedation 30 minutes before the procedure在術前 30 分鐘給予鎮靜劑
- DRemoving all pillows from under the head移除頭部下方的所有枕頭
— Explanation · 中文詳解 —
腰椎穿刺需透過胎兒姿勢（fetal position）將腰椎棘突間隙拉開，增加穿刺成功率並減少損傷風險。若病人移動或姿勢不正確，容易導致針頭傷及神經或骨骼，因此協助維持此姿勢是護理人員在過程中的核心職責。
Lumbar puncture requires the fetal position to widen the spaces between the lumbar spinous processes, increasing the success rate and reducing the risk of injury. If the client moves or is positioned incorrectly, the needle can easily injure nerves or bone; therefore, helping maintain this position is a core responsibility of the nurse during the procedure.
✦ 台美臨床差異
美台兩地在腰椎穿刺護理標準一致，但在術後平躺時限的建議上，部分機構已轉為臨床評估決定而非強制長時間平躺。