護理師照護一名意識混亂且反覆嘗試拔除靜脈輸液管（IV）的高齡病人。護理師應首先嘗試哪項介入措施？
A nurse is caring for an older adult client who is confused and repeatedly attempting to pull out an intravenous (IV) line. Which intervention should the nurse attempt first?
- ARequest a 1-on-1 sitter to remain with the client.請求安排一對一看護陪伴病人。
- BHide the IV site with a long-sleeved gown or stockinette.✓ 正解用長袖病服或網套遮蓋靜脈留置針部位。
- CApply soft wrist restraints to both arms.對雙臂施加軟質手腕約束帶。
- DObtain a prescription for a sedative medication.開立鎮靜劑處方。
這題考察的是『約束最少化原則』（Least Restrictive Environment）。對於意識混亂病人干擾醫療設備的情況，護理首選應是非侵入性、非約束性的替代方案。選項 B（覆蓋 IV 部位）是一種簡單有效的干擾控制技術，若病人看不到管路，通常會減少拔除的衝動。這屬於環境與視覺上的調整。選項 C（約束）和 D（化學約束/鎮靜劑）都具有較高的法律與倫理門檻，必須在所有替代方案無效後才考慮。選項 A（1對1看護）雖然有效但耗費資源極大，且在優先順序上，護理師應先嘗試能獨立執行的簡單替代方案（如覆蓋或分散注意力）。
This question tests the principle of the least restrictive environment. For a confused client interfering with medical devices, the first nursing choice should be a non-invasive, non-restrictive alternative. Option B (covering the IV site) is a simple yet effective distraction control technique; if the client cannot see the tubing, the urge to pull it out is usually reduced. This represents an environmental and visual modification. Options A (physical restraints) and D (chemical restraint/sedative) carry high legal and ethical thresholds and should be considered only after all alternatives have failed. Option A (1-on-1 sitter), while effective, is highly resource-intensive; in terms of priority, the nurse should first attempt simple, independently executable alternatives such as covering or distraction.
美國醫院對於物理約束（Restraints）有極嚴格的法規限制（如 CMS 規範），每 2 小時需解開評估且醫囑需每日更新。台灣雖然也有約束指引，但在人力不足時，臨床上使用約束的門檻有時較低，考生需特別注意 NCLEX 對『替代方案優先』的堅持。