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基本照護與舒適 · MEDIUM · MCQ

護理師照護一位薦骨處有第二級壓瘡的病人,下列哪項處置最合適?

A nurse is caring for a client with a Stage 2 pressure ulcer on the sacrum. Which intervention is appropriate?

  • AMassage the reddened area to improve circulation
    按摩發紅區域以改善血液循環
  • BReposition the client every 4 hours
    每 4 小時為病人更換姿勢
  • CApply a hydrocolloid dressing to the site✓ 正解
    在患處塗佈水膠體敷料
  • DKeep the wound dry by using a heat lamp
    使用熱燈保持傷口乾燥
Explanation · 中文詳解

第二級壓瘡(Stage 2 pressure ulcer)涉及表皮與部分真皮受損,使用水膠體敷料(Hydrocolloid)可維持濕潤癒合環境並隔離外界污染,促進修復。按摩紅斑區域會對脆弱組織造成機械性損傷,應禁止。熱燈可能導致燒傷,不建議使用。翻身間隔通常需小於 2 小時。護理師應選擇適當敷料並執行正確減壓措施,以保護傷口並加速癒合。

A Stage 2 pressure ulcer involves damage to the epidermis and part of the dermis. Using a hydrocolloid dressing maintains a moist healing environment and provides a barrier against external contamination, promoting repair. Massaging the reddened area causes mechanical injury to fragile tissue and should be avoided. Heat lamps can cause burns and are not recommended. Repositioning should generally occur at intervals of less than 2 hours. The nurse should select an appropriate dressing and implement proper pressure relief measures to protect the wound and accelerate healing.

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