護理師正在審閱一位有壓瘡風險的病人的照護計畫。下列哪項措施解決了最主要的風險因子？
A nurse is reviewing the care plan for a client at risk for pressure injuries. Which intervention addresses the most significant risk factor?
- ARepositioning the client at least every 2 hours✓ 正解至少每2小時為病人翻身
- BUsing a specialized pressure-relieving mattress使用特殊減壓床墊
- CApplying a moisture barrier cream塗抹水分隔離霜
- DEnsuring adequate nutritional intake確保充足的營養攝取
壓瘡（Pressure injury）的核心成因是組織受到持續性的壓力，導致局部缺血與壞死。護理照護計畫中，最有效的預防手段是消除持續壓力。每兩小時翻身一次（Turn every 2 hours）是臨床標準，能讓受壓區域恢復血液灌流。儘管營養與輔具也很重要，但物理性卸壓（Offloading）是解決壓力源最直接的措施。
The core cause of pressure injuries is sustained pressure on tissue, which leads to local ischemia and necrosis. In the plan of care, the most effective preventive measure is the elimination of sustained pressure. Repositioning the client at least every 2 hours is the clinical standard, allowing the compressed area to regain perfusion. Although nutrition and specialized equipment are also important, physical offloading is the most direct measure for addressing the source of pressure.