護理師為一位有約束醫囑的病人規劃照護計畫，下列哪項措施是正確的？
A nurse is planning care for a client who has a prescription for restraints. Which of the following actions should the nurse take?
- ACheck the client's skin integrity every 2 hours✓ 正解每2小時檢查病人的皮膚完整性
- BObtain a PRN order for restraints to be used as needed取得約束措施的PRN（必要時）醫囑以便按需使用
- CEnsure the restraint is tied to the side rail確保約束帶綁在床欄上
- DRemove the restraints every 4 hours for range-of-motion exercises每4小時解除約束以進行關節活動範圍運動
約束病人必須嚴格遵循保護病人安全與人權的原則。約束醫囑必須是針對單次發生，嚴禁開立 PRN（必要時使用）處方。約束帶應固定在床架上而非床欄，以免床欄升降造成病人受傷。每兩小時檢查皮膚完整性、循環與神經狀況是必要護理，並需定時執行關節活動以預防攣縮。
Restraint of a client must strictly follow principles that protect the client's safety and rights. A restraint order must be for a single specific episode, and a PRN (as-needed) order is strictly prohibited. Restraints should be tied to the bed frame rather than to the side rail, to prevent injury when the side rail is raised or lowered. Assessment of skin integrity, circulation, and neurological status every two hours is required nursing care, and range-of-motion exercises should be performed regularly to prevent contractures.
美國法規對約束要求極為嚴格，需在 1 小時內由醫師親自評估；台灣醫院評鑑亦嚴格限制約束之必要性。