— 基本照護與舒適 · EASY · MCQ —
護理師協助一位老年病人進行個人衛生以維持皮膚完整性。下列哪項措施最能有效預防壓瘡形成？
A nurse is assisting an elderly client with personal hygiene to maintain skin integrity. What is the most appropriate action to prevent pressure injury formation?
- AReposition the client at least every 2 hours✓ 正解至少每2小時為病人翻身
- BUse hot water for daily bathing使用熱水每日洗澡
- CMassage reddened bony prominences按摩發紅的骨突出處
- DApply talcum powder to all skin folds在所有皮膚皺摺處塗抹滑石粉
— Explanation · 中文詳解 —
預防壓瘡（Pressure Injury）的核心在於減壓與保護皮膚完整性。每兩小時翻身（A）是標準護理程序，能確保組織有足夠的血液灌流。按摩發紅的骨突處（C）是禁忌，因為這會導致深層組織進一步受損。滑石粉（D）會阻塞毛孔且造成呼吸道刺激，不建議使用。熱水（B）會破壞皮脂膜，加重皮膚乾燥。維持正確的翻身頻率與減壓措施是預防壓瘡的最有效方法。
Pressure injury prevention centers on offloading and skin integrity. Repositioning every 2 hours (A) ensures tissue perfusion. Massaging reddened bony prominences (C) is contraindicated as it worsens deep tissue damage. Talcum powder (D) causes pore occlusion and respiratory irritation. Hot water (B) strips natural oils and increases skin dryness.