— 安全與感染控制 · MEDIUM · MCQ —
護理師進入病室發現病人跌倒在地，優先採取的行動為何？
A nurse enters a room and finds a client on the floor. Which action is the nurse's priority?
- AComplete an incident report填寫事故報告
- BAssess the client for injuries✓ 正解評估病人是否有受傷
- CHelp the client back into bed協助病人回到床上
- DNotify the physician immediately立即通知醫師
— Explanation · 中文詳解 —
在 NCLEX 考試中，處理跌倒事件遵循「評估優先（Assessment First）」原則。護理師發現病人倒地，第一步是評估其生命徵象、意識狀態及是否有明顯外傷（特別是頭部、頸部與骨折）。在未確認受傷程度前，禁止隨意移動病人，以免造成二次傷害（如脊椎損傷加劇）。確認病人狀況穩定後，再進行後續處置、通知醫師及撰寫報告。
In NCLEX, falls follow the Assessment First principle. The nurse first assesses vital signs, consciousness, and visible injuries (especially head, neck, fractures). Until injury severity is determined, do not move the client to avoid secondary harm (worsened spinal injury). After confirming stability, proceed with further actions, notification, and incident report.