護理師照護一位意識混亂且反覆嘗試拔除靜脈導管的病人。護理師應優先實施哪項措施？
A nurse is caring for a client who is confused and repeatedly attempts to pull out their IV line. Which intervention should the nurse implement first?
- APlace the client in a room near the nurses' station將病人安置在護理站附近的病房
- BApply soft wrist restraints to both arms雙臂使用軟質手腕約束帶
- CCover the IV insertion site with a gauze wrap or stockinette✓ 正解以紗布纏繞或彈性繃帶覆蓋靜脈導管插入處
- DRequest a prescription for a sedative medication申請鎮靜劑處方
本題測試的是「最少限制原則（Least Restrictive Environment）」。當病人出現干擾醫療器材的行為時，護理師應先採取非侵入性且非限制性的干預。選項 C 將 IV 部位覆蓋起來，讓病人「看不見」管路，這通常能有效減少視覺刺激引起的拔管行為，且完全不限制病人活動。選項 A（靠近護理站）有助於觀察，但不能直接防止拔管。選項 B（約束）與選項 D（藥物）都屬於較高等級的限制，根據法律與倫理規範，必須在所有非限制性措施失敗後，且有醫師處方時才能使用。臨床思維應永遠從最簡單、最不具侵入性的方法開始。
This question tests the principle of the least restrictive environment. When a patient interferes with medical equipment, the nurse should first apply non-invasive, non-restrictive interventions. Option C covers the IV site so that the patient cannot 'see' the tubing, which often effectively reduces removal behavior driven by visual stimulation without limiting the patient's mobility. Option A (placement near the nurses' station) improves observation but does not directly prevent removal. Options A (restraints) and D (medications) are higher-level restrictions; according to legal and ethical standards, these may be used only after less restrictive measures have failed and only with a physician's order. Clinical reasoning should always begin with the simplest and least invasive approach.
美國對「約束（Restraint）」的定義與規範極其嚴格，護理師必須每 2 小時評估並記錄，且處方時效極短（通常 24 小時）；台灣雖也有規範，但在臨床執行上，對於預防拔管的約束門檻相對較低，考試時需採美規嚴格標準。