— 安全與感染控制 · HARD · MCQ —
一位病人因深層且受污染的撕裂傷抵達急診，且破傷風疫苗接種史不明。護理師應優先採取哪項行動？
A client arrives at the emergency department with a deep, contaminated laceration and unknown tetanus vaccination status. Which action is the priority?
- AAdminister tetanus toxoid施打破傷風類毒素
- BDetermine the date of the last tetanus shot確認最後一次破傷風疫苗注射日期
- CAssess the wound site✓ 正解評估傷口部位
- DAdminister tetanus immune globulin (TIG)施打破傷風免疫球蛋白 (TIG)
— Explanation · 中文詳解 —
護理評估永遠是第一優先。在處理任何傷口前，必須先評估傷口的深度、污染程度及組織受損情況，以便決定後續的醫療與感控措施。若傷口極度污染，評估其血液循環與神經損傷亦同等重要，再進行後續的免疫球蛋白與疫苗接種計畫。
Nursing assessment is always the first priority. Before treating any wound, the depth, degree of contamination, and tissue damage must be assessed in order to determine subsequent medical and infection-control actions. If the wound is heavily contaminated, assessment of circulation and neurologic damage is equally important before proceeding with the immunoglobulin and vaccination plan.
✦ 台美臨床差異
美國醫院有嚴格的破傷風預防指南（CDC），台灣臨床多視醫師經驗給予破傷風類毒素或球蛋白，護理師需精確紀錄傷口狀況。