— 安全與感染控制 · MEDIUM · MCQ —
護理師照護一位使用約束帶的病人，下列哪項行動是適當的？
A nurse is caring for a client in restraints. Which action is appropriate?
- AAttach restraints to the side rails將約束帶繫於床欄上
- BEnsure two fingers can fit between the restraint and skin✓ 正解確保約束帶與皮膚之間可放入兩指
- CCheck for skin integrity every 4 hours每4小時檢查皮膚完整性
- DRemove restraints only when the client is sleeping僅在客戶睡覺時移除約束帶
— Explanation · 中文詳解 —
約束帶的使用屬於限制病人行動的侵入性措施，必須嚴格遵守安全規範以預防併發症。核心重點在於保護血液循環與皮膚完整性，並防止因意外導致的傷害。約束帶應繫於床架（bed frame）而非護欄（side rails），因為護欄會隨床位調整移動，可能導致病人肢體被拉扯受傷。定期評估與適當的鬆緊度是降低約束風險的關鍵。
The use of restraints restricts patient movement and is an invasive measure; strict safety standards must be followed to prevent complications. The core focus is on protecting circulation and skin integrity and preventing inadvertent injury. Restraints should be secured to the bed frame, not to the side rails, because the side rails move when adjusted, which could pull on the patient's limbs and cause injury. Regular assessment and appropriate tension are key to minimizing restraint-related risk.