護理師評估一位住院三天的病人，下列哪些發現應優先處理以預防醫源性合併症？（選所有適合的）
A nurse is performing an assessment of a client who has been hospitalized for 3 days. Which findings should the nurse prioritize to prevent hospital-acquired complications? (Select all that apply.)
- ARedness and warmth at the peripheral IV insertion site✓ 正解周邊靜脈注射插入部位紅腫和發熱
- BSmall amount of clear yellow urine in the drainage bag引流袋中有少量清澈黃色的尿液
- CDecreased lung sounds in the lower lobes during auscultation✓ 正解聽診時肺葉底部呼吸音減弱
- DClient reports inability to defecate for three days病人報告三天無法排便
- EStage 1 erythema (non-blanchable redness) over the sacral area✓ 正解薦骨區域有一級紅斑（非褪色性紅斑）
住院 3 天以上的病人易發生院內合併症。A. IV 部位紅腫與溫熱顯示靜脈炎徵象（phlebitis），需立即拔除導管以防 CRBSI；C. 肺底呼吸音減弱提示肺塌陷或肺炎，需鼓勵深呼吸、咳嗽、IS；E. 薦骨第一級非褪色性紅斑為皮膚壓力性損傷的早期警訊，需立即翻身與減壓措施。其他選項：B. 少量清澈尿液雖需追蹤但非急性併發症；D. 便秘常見且非危及生命，可後續處理。
Clients hospitalized for 3 or more days are at increased risk of hospital-acquired complications. A. Redness and warmth at the IV site indicate signs of phlebitis; the catheter must be removed immediately to prevent CRBSI. C. Decreased breath sounds in the lower lobes suggest atelectasis or pneumonia; encourage deep breathing, coughing, and incentive spirometry. E. Stage 1 non-blanchable erythema over the sacrum is an early warning of a pressure injury and requires immediate repositioning and pressure-relief measures. Other options: B. A small amount of clear urine should be tracked but is not an acute complication. D. Constipation is common and not life-threatening; it can be addressed later.
美國護理記錄中對於壓瘡分級與導管評估非常嚴格，與品質指標（Core Measures）掛鉤，台灣則較著重臨床實務評估。