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健康促進與維護 · MEDIUM · MCQ

為預防活動受限病人產生壓瘡,護理師應優先採取何種措施?

Which action should the nurse prioritize to prevent pressure injuries in a patient with limited mobility?

  • AReposition the client every 2 hours✓ 正解
    每2小時為病人翻身
  • BApply powder to keep skin dry
    塗抹滑石粉以保持皮膚乾燥
  • CUse a donut-shaped cushion for support
    使用甜甜圈形坐墊提供支撐
  • DMassage reddened bony prominences
    按摩發紅的骨突部位
Explanation · 中文詳解

預防壓瘡(pressure injury)的核心是減壓(pressure relief)。活動受限的病人由於無法自行變換姿勢,受壓點的血液灌流會持續中斷,導致組織缺氧壞死。每兩小時翻身一次是預防壓瘡的臨床標準,能使受壓部位恢復血液循環。其他選項如按摩紅腫處會傷害原本脆弱的皮膚毛細血管;爽身粉可能在潮濕皮膚上結塊,反而增加摩擦;甜甜圈坐墊則會造成周邊組織血液循環阻斷,應避免使用。

The core of pressure injury prevention is pressure relief. In patients with limited mobility, the inability to change position independently leads to continued interruption of blood flow at pressure points, resulting in tissue hypoxia and necrosis. Repositioning every 2 hours is the clinical standard for pressure injury prevention, as it restores circulation at compressed sites. Other options, such as massaging reddened areas, damage already fragile skin capillaries; powder may cake on moist skin, increasing friction; and donut-shaped cushions interrupt circulation in surrounding tissue and should be avoided.

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