— 照護管理 · EASY · MCQ —
護理師正在督導一位新進護理人員進行周邊靜脈注射（IV），下列哪項行為需要督導者介入？
A nurse is supervising a newly licensed nurse who is preparing to insert a peripheral IV line. Which action by the new nurse requires intervention?
- AShaving the insertion site to ensure better visibility✓ 正解刮除穿刺處毛髮以確保視野清晰
- BPerforming hand hygiene before touching the client在接觸病人前執行手部衛生
- CApplying a tourniquet 4-6 inches above the site在穿刺點上方 4-6 英寸處綁紮止血帶
- DSelecting a vein on the non-dominant forearm選擇非慣用手前臂的靜脈
— Explanation · 中文詳解 —
刮毛容易造成皮膚表面細微割傷，增加導管相關血流感染（CRBSI）的風險。目前實證護理建議應使用修剪方式而非刮除，以保護皮膚完整性。其餘選項皆符合無菌操作原則，如選擇非慣用手可減少活動干擾，手部衛生是預防感染之基石。
Shaving creates microabrasions on the skin surface, increasing the risk of catheter-related bloodstream infection (CRBSI). Current evidence-based practice recommends clipping rather than shaving the area to preserve skin integrity. The other options align with proper aseptic technique: selecting the non-dominant arm reduces interference with the client's activities, and hand hygiene is the foundation of infection prevention.
✦ 台美臨床差異
台美臨床對剃毛的規範趨於一致，均強調避免物理性損傷皮膚完整性。