— 降低風險 · HARD · MCQ —
護理師照護一位新放置周邊導管中央靜脈導管（PICC）的病人，最優先的護理措施為何？
A nurse is caring for a client with a new peripherally inserted central catheter (PICC). What is the priority nursing action?
- AVerify the radiographic report confirming tip placement✓ 正解查驗確認導管尖端位置的放射學報告
- BFlush the line with heparinized saline every shift每班次以肝素化生理食鹽水沖洗導管
- CAdminister antibiotics through the PICC line經 PICC 導管給予抗生素
- DChange the dressing using clean technique以清潔技術更換敷料
— Explanation · 中文詳解 —
周邊導管中央靜脈導管（PICC）放置後，最嚴重的風險是導管頂端位置錯誤（如進入頸靜脈或心臟腔室），可能導致血管穿孔或心律不整。因此，在護理師開始執行任何給藥或輸液前，必須確認放射科報告（Chest X-ray report）證實導管頂端位於上腔靜脈（SVC）。這是確保病人安全、預防併發症的最高優先級護理措施。
After PICC insertion, the most serious risk is malposition of the catheter tip (e.g., into jugular vein or cardiac chamber), which can cause vascular perforation or arrhythmia. Therefore, before any administration or infusion, the nurse must verify the radiographic report confirming tip placement in the superior vena cava (SVC). This is the highest priority safety step to prevent complications.