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基本照護與舒適 · EASY · MCQ

護理師協助一位手術後活動受限的病人首次坐到床邊。護理師應優先採取哪項行動?

A nurse is assisting a client with limited mobility to sit at the edge of the bed for the first time after surgery. Which action should the nurse take first?

  • AAssess the client's blood pressure while lying down
    評估病人平躺時的血壓
  • BDangle the client's legs on the side of the bed
    讓病人雙腿垂於床緣
  • CApply non-skid socks to the client's feet
    為病人腳部穿上防滑襪
  • DRaise the head of the bed to a high Fowler's position✓ 正解
    將床頭抬高至半坐臥位(High Fowler's position)
Explanation · 中文詳解

手術後病人首次離床活動,首要考量是「血液動力學穩定性」。因長期臥床導致血管張力適應不良,直接起身容易引發姿勢性低血壓(Orthostatic Hypotension)。護理流程應遵循漸進原則:先抬高床頭(High Fowler's),觀察病人反應,確認無頭暈後再執行垂足(Dangling),最後才起身。

When a postoperative client is getting out of bed for the first time, the primary consideration is hemodynamic stability. Because prolonged bed rest impairs adaptation of vascular tone, sitting up too quickly easily induces orthostatic hypotension. The nursing procedure should follow a stepwise approach: first elevate the head of the bed to a high Fowler's position, observe the client's response, and then proceed to dangling the legs once it is confirmed that the client is not dizzy, and only afterward stand the client up.

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