護理師正在照護一名高跌倒風險的病人。護理師應執行哪些處置？（選所有適合的）
A nurse is caring for a client who is at high risk for falls. Which interventions should the nurse implement? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床保持在最低位置
- BPlace the bedside commode close to the bed✓ 正解將床邊便盆椅放置在靠近床的位置
- CApply all four side rails in the upright position將所有四個床欄豎起
- DEnsure the call light is within the client's reach✓ 正解確保呼叫鈴在病人可觸及的範圍內
- EProvide non-skid footwear for ambulation✓ 正解提供行走時穿著的防滑鞋
跌倒防護的核心在於『環境安全化』與『消除誘發因素』。將病床維持在最低位置（A）能降低萬一跌落時的受傷嚴重度。提供床邊便盆椅（B）可以減少衰弱病人為了上廁所而走遠路的體力消耗與風險。確保呼叫鈴在伸手可及處（D）能讓病人在需要幫助時及時求援，避免自行冒險下床。穿著防滑鞋（E）則增加了行走時的穩定性。選項 C（拉起四邊床欄）是錯誤的，因為這在美國護理標準中被視為一種『生理約束』（Restraint），且可能增加病人試圖翻越床欄而導致更嚴重跌傷的風險，除非有特定醫囑或特殊情況，否則不應常規使用四邊床欄。
The core of fall prevention is environmental safety and the elimination of contributing factors. Keeping the bed in the lowest position (A) reduces the severity of injury if a fall occurs. Providing a bedside commode (B) reduces the physical exertion and risk associated with debilitated clients walking long distances to the toilet. Ensuring that the call light is within reach (D) allows the client to summon help promptly when needed, thus avoiding risky attempts to get out of bed alone. Wearing non-skid footwear (E) increases stability during ambulation. Option C (raising all four side rails) is incorrect because, under U.S. nursing standards, this is considered a form of physical restraint and can increase the risk of more severe injury from clients attempting to climb over the rails; four side rails should not be used routinely unless specifically ordered or under particular circumstances.
在美國，對『四邊床欄』作為約束的法律定義非常嚴格，護理師需極力避免。台灣臨床上為了怕病人掉下來，往往習慣性拉起四邊床欄，甚至認為這是保護。然而，NCLEX 遵循美國標準，將四邊床欄視為危險的約束，考生必須扭轉這種傳統觀念。