一名病人被診斷為深層靜脈栓塞 (DVT)。哪項護理干預對於降低肺栓塞風險最重要？
A client is diagnosed with a deep vein thrombosis (DVT). Which nursing intervention is most important for reducing the risk of pulmonary embolism?
- AApply sequential compression devices (SCDs) to both legs雙腿套上順序加壓裝置 (SCDs)
- BMassage the affected leg to promote circulation按摩患肢以促進循環
- CEncourage vigorous range-of-motion exercises鼓勵劇烈的關節活動範圍運動
- DMaintain the client on bed rest with the affected limb elevated✓ 正解讓病人臥床休息並將患肢抬高
深層靜脈栓塞（Deep Vein Thrombosis, DVT）是指深層靜脈中形成血栓，最嚴重的併發症是肺栓塞（Pulmonary Embolism, PE），當血栓脫落隨血流進入肺動脈，可能危及生命。因此，急性 DVT 的護理重點在於預防血栓脫落和進一步形成，同時減輕患肢腫脹和疼痛。雖然臨床實踐在 DVT 的早期活動方面有所演進，但在 NCLEX 的傳統考點中，急性期的首要考量仍是避免任何可能導致血栓脫落的行為，以保護病人免於致命性 PE 的風險。
Deep Vein Thrombosis (DVT) refers to the formation of a thrombus in the deep veins. The most serious complication is Pulmonary Embolism (PE): when the thrombus dislodges and travels with the bloodstream to the pulmonary arteries, it can be life-threatening. Nursing care of acute DVT therefore focuses on preventing thrombus dislodgement and further thrombus formation, while reducing limb swelling and pain. Although clinical practice has evolved regarding early activity in DVT, in the traditional NCLEX framework the foremost consideration during the acute phase is still to avoid any behavior that could dislodge the thrombus, in order to protect the patient from the risk of fatal PE.
傳統上，急性 DVT 病人會被要求嚴格臥床休息。然而，近年來美國的臨床指南逐漸傾向於在抗凝血劑治療穩定後，鼓勵早期溫和活動（early ambulation），認為這有助於改善預後並減少血栓後症候群。台灣的臨床實踐也逐漸採納此觀點，但 NCLEX 考試可能仍側重於急性期預防血栓脫落的傳統考量，即臥床休息。