一位跌倒高風險病人，護理師應執行哪些介入措施？（選所有適合的）
A nurse is caring for a client at risk for falls. Which of the following interventions should the nurse implement? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床調至最低位置
- BPlace the call light within reach✓ 正解將呼叫鈴放置在觸手可及之處
- CApply physical restraints to keep the client in bed使用身體約束具以防止病人下床
- DPerform hourly rounding✓ 正解每小時進行巡房
- EEnsure the floor is free of clutter✓ 正解確保地面無雜物
跌倒預防是護理安全（Patient Safety）的基礎。策略包括環境調整（低床位、移除障礙物）、溝通（呼叫鈴在手邊）及定期評估（Hourly rounding）。Hourly rounding 能主動協助病人解決排泄、舒適度與體位需求，大幅降低病人因無人協助而自行下床跌倒的風險。物理約束非預防跌倒的首選，且需嚴格遵照醫囑與法律規範。
Fall prevention is fundamental to patient safety. Strategies include environmental modification (lowering the bed, removing obstacles), communication (keeping the call light within reach), and regular assessment (hourly rounding). Hourly rounding proactively addresses the client's elimination, comfort, and positioning needs, significantly reducing the risk that the client will get out of bed unassisted and fall. Physical restraints are not the first choice for fall prevention and must strictly follow physician orders and legal regulations.
美國醫院非常強調「No-Restraint Policy」。在美國，物理約束（Physical restraints）的使用門檻極高，必須有詳細的醫囑並頻繁評估，且需向病人與家屬解釋理由，護理師若非迫不得已不會主動使用。