哪一項評估發現表示護理師正確地為病人約束？
Which assessment finding indicates a nurse has correctly applied a restraint to a client?
- AThe restraint is only removed once a day for hygiene約束帶僅每天移除一次以進行清潔
- BThe restraint is tied to the side rail約束帶繫於床欄上
- CThe restraint is applied as tightly as possible to ensure immobility約束帶盡可能緊繃地綁紮，以確保病人無法活動
- DTwo fingers can fit between the restraint and the client's skin✓ 正解約束帶與病人皮膚之間可放入兩根手指的空間
約束（Restraint）的使用必須遵循「最少限制」原則。正確的約束評估包含確保病人神經血管循環（Neurovascular status）不受阻礙，物理上的標準是約束帶與皮膚間可放入兩根手指，避免過緊造成組織缺血或神經壓迫。此外，約束帶必須繫於床架（Bed frame）而非隨時升降的床欄（Side rail），以防止病人因床欄升降而受傷。
The use of restraints must follow the principle of least restriction. Correct restraint assessment includes ensuring that the client's neurovascular status is not compromised; the physical standard is that two fingers should fit between the restraint and the skin to avoid excessive tightness that would cause tissue ischemia or nerve compression. In addition, the restraint must be tied to the bed frame rather than to the side rails, which move during raising and lowering, to prevent injury to the patient.