護理師照護一位有跌倒病史的病人，哪項介入措施是安全優先考量？
A nurse is caring for a client with a history of falls. Which intervention is the priority for safety?
- AApplying physical restraints to the bed frame將身體約束固定在床架上
- BKeeping the bed in the lowest position with wheels locked✓ 正解保持床位在最低位置並鎖定輪子
- CEncouraging the client to walk only with help鼓勵病人僅在協助下行走
- DPlacing a sitter at the bedside 24/724 小時在床邊安排看護人員
預防跌倒是 NCLEX 的核心安全考題。針對跌倒高風險病人，護理措施應遵循「由低侵入性到高侵入性」的原則。環境安全（Environmental modification）是第一線介入，維持病床在最低高度可縮短病人若發生墜落時的距離，減少傷害程度；鎖定輪子則防止病人起身或轉位時病床滑動。其他選項如約束或專人看護屬於侵入性或高成本措施，需在評估跌倒預防計畫失效後才考慮，而非首選。
Fall prevention is a core NCLEX safety topic. For clients at high risk of falls, nursing interventions should follow the principle of moving from least to most restrictive. Environmental modification is the first-line intervention; keeping the bed at the lowest position shortens the distance of a potential fall and minimizes injury, while locking the wheels prevents the bed from moving when the client stands or transfers. Other options such as restraints or constant-observation sitters are invasive or resource-intensive measures and should be considered only if a fall-prevention plan fails, rather than as the first choice.
在美國，約束（Restraints）的使用受到聯邦法規（如 CMS Guidelines）極嚴格的監控，必須有醫師即時醫囑且需定期評估，絕非護理師可自行決定使用的介入。台灣臨床有時較依賴家屬照顧（類似 Sitter 概念），但在美國，Sitter 必須經過評估且資源配置通常非常嚴謹。