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降低風險 · MEDIUM · MCQ

護理師為疑似深層靜脈栓塞的病人進行評估,應避免執行下列哪項動作?

A nurse is performing a focused assessment on a client with a potential DVT. Which action should the nurse avoid?

  • AMeasuring the calf circumference
    測量小腿周徑
  • BMassaging the affected calf✓ 正解
    按摩患側小腿
  • CPalpating the calf for tenderness
    觸診小腿是否有壓痛
  • DAssessing for peripheral pulses
    評估周邊脈搏
Explanation · 中文詳解

疑似深層靜脈栓塞(DVT)時,臨床護理重點為「防止血栓脫落」。血栓若脫落隨血液循環流至肺部,將引發致命的肺栓塞(Pulmonary Embolism, PE)。因此,在診斷尚未排除前,任何可能對患肢造成機械性刺激、擠壓或導致血栓脫落的動作皆為絕對禁忌,必須優先採取絕對臥床休息與患肢抬高(Elevate)等保護措施。

When deep vein thrombosis (DVT) is suspected, the focus of nursing care is to prevent thrombus dislodgement. If the clot becomes dislodged and travels through the circulation to the lungs, it can cause a fatal pulmonary embolism (PE). Therefore, until the diagnosis is ruled out, any action that could provide mechanical stimulation, compression, or dislodgement of the thrombus to the affected limb is absolutely contraindicated, and protective measures such as strict bed rest and elevation of the affected extremity must take precedence.

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