— 安全與感染控制 · EASY · SATA —
護理師應採取哪些行動，為具有跌倒風險的高齡病人維持安全環境？（選所有適合的）
Which actions should the nurse take to maintain a safe environment for an elderly client at risk for falls? (Select all that apply.)
- AEnsure the call light is within reach✓ 正解確保呼叫器在觸手可及之處
- BKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- CKeep all four side rails in the up position將四片床欄全部拉起
- DProvide non-skid footwear✓ 正解提供防滑鞋
- EClear the floor of clutter and electrical cords✓ 正解清除地板上的雜物與電線
— Explanation · 中文詳解 —
跌倒預防的基本措施包括：紅鈴在手邊（A）、病床高度調至最低（B）、穿著止滑鞋（D）以及清除地面雜物（E）。C 錯誤：將四邊床欄全部拉起在美國被視為「非法約束（Restraint）」，可能導致病人試圖翻越床欄而造成更嚴重的跌倒。
Basic fall-prevention measures include keeping the call light within reach (A), maintaining the bed in the lowest position (B), providing non-skid footwear (D), and clearing the floor of clutter (E). Option C is incorrect: raising all four side rails is considered an "unlawful restraint" in the United States and may lead the patient to attempt climbing over the rails, resulting in more severe falls.
✦ 台美臨床差異
美國法規嚴格限制「全床欄（Four Rails Up）」的使用，視其為約束；台灣臨床仍普遍認為拉起四邊床欄是安全行為，這是兩國極大的觀念差異。