護理師為一位試圖拉扯腹部傷口的混亂病人穿戴腕部約束帶。護理師應採取哪項動作？
A nurse is applying wrist restraints to a confused client who is pulling at an abdominal incision. Which action should the nurse take?
- ASecure the restraint with a square knot以平結固定約束帶
- BEnsure two fingers can be inserted under the restraint✓ 正解確保約束帶下可插入兩根手指
- CTie the restraint to the side rails for easy access將約束帶繫在床欄上以便存取
- DRemove the restraint every 4 hours for range-of-motion exercises每 4 小時移除約束帶一次以進行關節活動度運動
約束帶的安全使用規範：1. 必須繫在床架（固定框架）而非床欄，以免移動床欄時拉傷病人。2. 鬆緊度應能容納兩指，以維持血循。3. 使用快速解開結 (Quick-release tie) 而非死結。4. 至少每 2 小時移除一次，檢查皮膚與執行關節活動（ROM），而非 4 小時。
Safety standards for the use of restraints: 1. They must be tied to the bed frame (a fixed structure) rather than the side rails, to prevent injury to the client when the rails are moved. 2. The fit should allow two fingers to be inserted underneath in order to maintain circulation. 3. A quick-release tie must be used instead of a fixed (square) knot. 4. The restraint must be removed at least every 2 hours to inspect the skin and perform range-of-motion (ROM) exercises, not every 4 hours.
美國對約束的文書記錄（每 15 分鐘觀察、每 2 小時解開、醫師醫囑時效）要求極為嚴格；台灣在臨床執行上的觀察頻率可能依醫院規範略有不同。