一位病人被列為跌倒高風險。護理師應執行哪些護理措施以確保病人安全？（選所有適合的）
A client is placed on falls precautions. Which nursing interventions should be implemented to ensure the client's safety? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BKeep all four side rails in the up position將四片床欄全部拉起
- CPlace the call light within reach✓ 正解將呼叫鈴放置在病人觸手可及之處
- DProvide non-skid socks for ambulation✓ 正解提供防滑襪供病人行走時穿著
- EEnsure the room is well-lit during nighttime✓ 正解確保夜間房間照明充足
跌倒防範是護理安全的核心。正確措施包括：1. 保持病床在最低位置，以減少萬一跌落時的衝擊力。2. 呼叫鈴必須觸手可及，確保病人需要協助時不必起身拿取。3. 提供防滑襪（Non-skid socks）或合腳的鞋子，增加行走時的摩擦力。4. 充足的照明（尤其是夜間的小夜燈）能幫助老人或視力不佳者辨識環境障礙。特別注意選項 B：將四個床欄全部拉起在法律上被視為「身體約束（Restraint）」，這可能導致病人試圖翻越床欄而從更高處跌落，反而更危險。除非有特定醫囑或特殊情況，否則通常只拉起靠近床頭的兩個床欄。安全環境的營造優於物理性的束縛。
Fall prevention is central to nursing safety. Correct measures include: 1. Keeping the bed in the lowest position to reduce impact force should a fall occur. 2. Keeping the call light within reach so the client does not have to get up to reach it when help is needed. 3. Providing non-skid socks or properly fitting shoes to increase friction during ambulation. 4. Adequate lighting (especially nightlights at night) to help older adults or those with poor vision identify environmental obstacles. Pay special attention to option B: raising all four side rails is legally considered a 'physical restraint' and may cause the client to attempt to climb over the rails and fall from a greater height, which is actually more dangerous. Unless there is a specific order or special situation, typically only the two side rails near the head of the bed are raised. Creating a safe environment is preferable to physical restraint.
美國非常強調「No Restraint」政策，四邊床欄拉起需嚴格審核。台灣臨床上為了怕病人掉下來，常習慣將四邊床欄拉起，但在 NCLEX 邏輯中，這是不安全的做法，因為這會迫使想下床的病人從更高的地方（床尾或跨越床欄）翻下來。