— 基本照護與舒適 · MEDIUM · MCQ —
一位骶骨壓瘡病人預定翻身，護理師應給予助理人員（UAP）什麼指示？
A client with a pressure injury on the sacrum is scheduled for a position change. Which instruction should the nurse give the unlicensed assistive personnel (UAP)?
- AUse a donut cushion to elevate the sacrum使用甜甜圈坐墊墊高薦骨
- BSlide the client across the bed sheets to minimize lifting在床單上滑動病人以減少搬抬
- CAvoid positioning the client directly on the sacral wound✓ 正解避免讓病人直接壓迫薦骨傷口
- DMassage the reddened skin around the wound按摩傷口周圍發紅的皮膚
— Explanation · 中文詳解 —
針對壓瘡照護，壓力卸除是首要任務。直接壓迫傷口會惡化血液循環，導致組織缺氧。D 錯誤：按摩紅腫處會傷害深層脆弱組織。B 錯誤：拖行會產生剪力（Shear），撕裂皮膚。A 錯誤：甜甜圈墊會造成局部水腫和血液回流受阻。
In pressure ulcer care, pressure offloading is the top priority. Direct pressure on the wound worsens circulation and leads to tissue hypoxia. D is incorrect: massaging reddened tissue damages fragile deep tissue. B is incorrect: sliding the client creates shear, tearing the skin. A is incorrect: a donut cushion causes local edema and impaired venous return.
✦ 台美臨床差異
美國護理師常授權 UAP 執行翻身，台灣通常由照服員協助，護理師需負起監督與指導責任。