護理師正在審閱一位 2 小時前剛完成全人工髖關節置換術病人的護理計畫。為了預防潛在併發症，哪項介入措施應列為優先？
The nurse is reviewing the plan of care for a client who had a total hip arthroplasty 2 hours ago. Which intervention is the priority to prevent a potential complication?
- APlace an abduction pillow between the client's legs.✓ 正解在病人雙腿之間放置外展枕。
- BReview the client's pre-operative hemoglobin level.檢視病人術前的血紅素水平。
- CInstruct the client on how to use an incentive spirometer.指導病人如何使用誘發性肺量計。
- DAdminister prophylactic antibiotics.給予預防性抗生素。
核心概念是預防全髖關節置換術後最常見且危險的早期併發症：脫位（Dislocation）。術後初期，關節周圍組織尚未癒合，任何內收（Adduction）或過度旋轉動作都可能使人工關節脫出。使用外展枕（Abduction pillow）能維持髖關節於安全角度，這是術後立即護理的標準動作。雖然肺量計（C）可預防肺炎，抗生素（D）可預防感染，但在手術剛結束的數小時內，維持關節結構的穩定性是物理安全的最高優先。護理師必須確保病人在翻身或移動時始終保持外展姿勢，這直接關係到手術的成敗與病人的安全。
The core concept is preventing the most common and dangerous early complication after total hip arthroplasty: dislocation. In the immediate postoperative period, the tissues surrounding the joint have not yet healed, and any adduction or excessive rotation can dislodge the prosthesis. An abduction pillow keeps the hip joint at a safe angle and is a standard immediate postoperative nursing intervention. Although an incentive spirometer (C) can prevent pneumonia and antibiotics (D) can prevent infection, in the first several hours after surgery, maintaining joint stability is the highest physical safety priority. The nurse must ensure that the client remains in abduction during all turning and movement, as this directly determines surgical success and client safety.
美國 NCLEX 非常強調『術後限制姿勢』以預防脫位的教育；台灣臨床上除了外展枕，有時也會強調沙袋加壓或特定的翻身角度，但在考題中，『維持外展避免內收』是普世公認的正確答案。