RN 督導新人護理師,新人準備執行下列操作,何者需要 RN 立即介入?
An RN is supervising a new graduate nurse. The graduate nurse is preparing to perform an intervention. Which action by the graduate nurse requires immediate intervention by the RN?
- ADocumenting the client's output after a shift在輪班後記錄病人的排出量
- BTurning a client with a recent spinal surgery by themselves✓ 正解獨自翻轉剛接受脊椎手術的病人
- CChecking the wristband before administering medication給藥前檢查手環
- DAsking the patient about their preferred name詢問病人偏好的名字
脊椎手術後的病人,為了避免手術部位產生剪力(Shearing force)或脊柱扭轉導致手術失敗或神經損傷,必須採取「滾動式翻身(Log-rolling)」。此操作需要至少 2 名護理人員同時進行,以維持頸、胸、腰椎的直線排列。新人護理師單獨翻身違反了脊椎術後照護的安全規範,極具危險性,RN 必須立即介入以防止病患發生神經損傷。
After spinal surgery, the patient must be log-rolled to avoid shearing forces or torsion of the spine that could cause surgical failure or neurologic injury. Log-rolling requires at least two staff members to maintain alignment of the cervical, thoracic, and lumbar spine. A new graduate turning the patient alone violates spinal post-op safety standards and is dangerous; the RN must intervene immediately to prevent neurologic injury.