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照護管理 · HARD · MCQ

護理師在監督一位新進護理師照護使用硬脊膜外連續輸注的病人,下列哪項行為顯示需要護理師介入指導?

A nurse is supervising a newly licensed nurse who is caring for a client with a continuous epidural infusion. Which action by the new nurse indicates a need for intervention?

  • AThe nurse assesses the client's dermatome level for sensory loss
    評估病人的皮節感覺喪失層級
  • BThe nurse disconnects the tubing to administer an IV antibiotic✓ 正解
    斷開導管以給予靜脈抗生素
  • CThe nurse checks the infusion site for signs of infection or leakage
    檢查輸注部位是否有感染或滲漏跡象
  • DThe nurse assists the client to turn every 2 hours
    協助病人每兩小時翻身
Explanation · 中文詳解

硬脊膜外(Epidural)導管直接連接至脊髓腔周圍,屬於無菌操作的最高等級區域。任何斷開連接的行為都極大增加了細菌進入脊髓腔的風險,可能導致硬脊膜外膿瘍或腦膜炎,這是災難性的併發症。新進護理師若擅自斷開管路,顯示其缺乏對無菌技術(Aseptic technique)與導管感染風險的認識,護理師必須立即介入指導,並重新評估其執行程序的能力。

An epidural catheter is directly connected to the area around the spinal canal and represents the highest level of sterile operation. Any disconnection greatly increases the risk of bacteria entering the spinal canal, potentially causing an epidural abscess or meningitis – catastrophic complications. If a new nurse disconnects the line without authorization, it indicates a lack of understanding of aseptic technique and catheter infection risk, and the supervising nurse must intervene immediately, providing guidance and reassessing the new nurse's competency in performing the procedure.

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