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照護管理 · MEDIUM · SATA

護理師將中風病人的任務委派給 UAP,下列哪些任務是適當的?(選所有適合的)

A nurse is delegating tasks to a UAP for a client with a stroke. Which tasks are appropriate? (Select all that apply.)

  • AMeasuring the client's intake and output✓ 正解
    測量病人的攝入量與排出量
  • BAssessing the client's ability to swallow
    評估病人的吞嚥能力
  • CAssisting with repositioning every 2 hours✓ 正解
    協助每 2 小時翻身
  • DPerforming passive range-of-motion exercises✓ 正解
    執行被動關節活動運動
  • EFeeding a client who has a high risk of aspiration
    餵食有高誤吸風險的病人
Explanation · 中文詳解

UAP 適合執行不具風險、常規性的技術任務。A(紀錄 I/O)、C(翻身)、D(被動關節運動)均屬於穩定病人的常規照護。B(評估吞嚥)需要 RN 進行臨床判斷;E(高吸入性肺炎風險的餵食)風險過高,尤其在中風急性期應由護理師親自執行或在評估後由專業人員引導。

UAPs are appropriate for performing routine, low-risk technical tasks. Recording I&O (A), repositioning (C), and passive range-of-motion exercises (D) are all routine care for stable clients. B (assessing swallowing ability) requires clinical judgment by the RN; E (feeding a client at high risk of aspiration) carries excessive risk and, especially in the acute stroke phase, should be performed by the nurse personally or by a trained professional after assessment.

✦ 台美臨床差異

美國 NCLEX 嚴格禁止委派「高風險餵食」給 UAP;台灣實務上常由家屬或看護餵食,護理師需加強監督與衛教。

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