— 安全與感染控制 · MEDIUM · MCQ —
護理師發現病人跌倒在地，第一優先行動為何？
A nurse finds a client on the floor. What is the first priority action?
- AHelp the client back to bed immediately立即協助病人回到床上
- BFill out an incident report填寫事件報告
- CCall the family to inform them通知家屬
- DAssess the client for injuries✓ 正解評估病人有無受傷
— Explanation · 中文詳解 —
當發現病人跌倒（Fall），護理師的首要行動必須是「評估（Assess）」。這包括評估意識狀態、生命徵象、有無明顯骨折、頭部外傷或出血。在未完成全面評估並排除脊椎損傷（Spinal injury）前，絕對不可冒然移動病人。移動病人可能會加重骨折或脊髓傷害。事件報告（Incident report）與通知家屬是後續處置，而非第一優先。
When a client is found on the floor after a fall, the nurse's first action must be to assess the client. This includes evaluating level of consciousness, vital signs, obvious fractures, head injury, and bleeding. The client should not be moved until a thorough assessment has ruled out spinal injury, as movement could worsen fractures or spinal cord damage. Completing an incident report and notifying the family are subsequent actions, not the first priority.