一位22歲女性在嚴重的車禍後12小時入院。她的右腿有深度撕裂傷並有靜脈點滴注射中。當註冊護理師 (RN) 正在記錄時，無照護佐 (UAP) 回報了以下數據：體溫 37.2°C，血壓 118/76 mmHg，心跳 88 次/分，呼吸 18 次/分，且個案表示她的腿部疼痛指數為 8/10。接下來 RN 應該將哪項處置交辦給 UAP？（選所有適合的）
A 22-year-old female is admitted 12 hours after a severe motor vehicle collision. She has a deep laceration on her right leg and an infused IV line. While the RN is charting, the UAP reports the following data: Temp 37.2°C, BP 118/76 mmHg, HR 88 bpm, RR 18 bpm, and the client rates her leg pain as 8/10. What action should the RN delegate to the UAP next? (Select all that apply.)
- AAdminister 400 mg oral Ibuprofen as PRN for the reported pain of 8/10.針對報告之 8/10 疼痛，給予 400 mg 口服 Ibuprofen（PRN）
- BAssist the deeply distressed client with taking a comfortable warm sponge bath.✓ 正解協助情緒困擾的嚴重病人進行舒適的溫水擦澡
- CAssess the severe leg laceration exactly for any active capillary bleeding or swelling.精確評估嚴重腿部撕裂傷是否有活動性毛細血管出血或腫脹
- DEmpty the urinary catheter collection bag entirely and precisely record the liquid output.✓ 正解完全排空導尿管集尿袋並精確記錄液體排出量
- EProvide non-pharmacological comfort by gently dimming the lights and repositioning her pillows.✓ 正解透過輕輕調暗燈光和重新調整枕頭位置，提供非藥物性舒適措施
本題測驗 UAP（無照護衛助理）的交辦範圍。UAP 的工作核心是執行非侵入性、具重複性且不需複雜臨床護理判斷的常規日常活動 (ADLs)。由於病患生命徵象目前極度穩定，交辦生活起居雜事非常安全。這包括：協助洗澡清潔（選項 B）、倒空尿袋並測量記錄尿量（選項 D），以及提供基礎的非藥物舒適照護如調整燈光與枕頭（選項 E）。選項 A 錯誤，即使是口服非處方藥 (OTC)，給藥 (Medication administration) 也是絕對禁止交給 UAP 執行的，至少需交辦給 LPN 或是 RN 親自給。選項 C 錯誤，觀察傷口是否有出血或腫脹屬於「護理生理評估 (Assessment)」，且可能暗示著嚴重的內出血併發症，這專屬於 RN 的最高執業範疇，UAP 只能看見血流出時「通報」，絕不能進行「醫學觀察與評估」。
This question tests UAP delegation scope. UAPs perform non-invasive, repetitive routine ADLs requiring no complex clinical judgment. Since vital signs are stable, delegating daily living tasks is safe. These include: assisting with bathing (B), emptying the urinary catheter bag and recording output (D), and providing basic non-pharmacological comfort like dimming lights and repositioning pillows (E). Option A is wrong—medication administration is strictly outside UAP scope, even OTC PRN oral analgesics, and must be performed by RN or LPN. Option C is wrong—wound assessment for bleeding or swelling is a nursing assessment requiring RN judgment and may signal serious internal bleeding; UAPs may only report visible blood but cannot perform medical observation and evaluation.
台灣的「護佐/病房助理」主要負責翻身拍背、擦澡、量V/S，這完全對應了美國 UAP 不能給藥、不能評估的核心概念。兩者考點高度雷同。