護理師照護一位術後發生左小腿深層靜脈栓塞（DVT）的病人，下列哪項護理措施是最高優先級？
A nurse is caring for a postoperative client who has developed a deep vein thrombosis (DVT) in the left calf. Which nursing intervention is the highest priority?
- AEncourage the client to ambulate frequently鼓勵個案經常下床走動
- BMassage the calf muscles to improve circulation按摩小腿肌肉以促進循環
- CMaintain bed rest as prescribed✓ 正解遵照醫囑維持臥床休息
- DApply warm, moist compresses to the affected area在患處施加溫濕敷
深層靜脈栓塞（DVT）的核心風險在於血栓脫落引發肺栓塞（PE），這是致命性的醫療併發症。對於急性 DVT 患者，最首要的處置是限制患肢活動以防止血栓脫落，並等待抗凝血藥物（如肝素或低分子肝素）開始產生效果。禁止下床走動（A）是為了防止血栓因肌肉收縮或血流速度改變而進入血液循環；禁止按摩患處（B）是因為物理壓力直接推擠血管可能導致血栓分離；熱敷（D）雖可緩解疼痛，但對防止肺栓塞沒有幫助，且可能導致血管擴張。臨床護理思路應優先執行絕對臥床處置，再配合藥物治療與後續監測，確保病人的生命安全不受肺栓塞威脅。
The major risk of deep vein thrombosis (DVT) is clot dislodgement leading to pulmonary embolism (PE), a fatal complication. For acute DVT, the priority is limiting movement of the affected limb to prevent embolization while awaiting therapeutic anticoagulation (heparin or LMWH). Ambulation (A) is forbidden because muscle contraction may dislodge the clot. Massaging (B) is contraindicated because direct pressure on the vessel may dislodge the clot. Warm compresses (D) may relieve discomfort but do not prevent PE and could promote vasodilation. The priority order is strict bed rest plus anticoagulant therapy and continued monitoring to protect the client from life-threatening pulmonary embolism.
美國醫院常見使用 SCD 氣動加壓器，若病人已確診 DVT 則通常會立即停用以防血栓移動，而台灣病房若有此類設備則需更加注意醫囑的變動狀況，特別是對於抗凝血劑的監測頻率，美國護理師常需負責監控 Anti-Xa 監測數據以調整劑量。