一位全膝關節置換術後第 2 天的病人，護理師發現病人不願使用誘發性肺量計 (incentive spirometer)。護理師的優先行動為何？
A client is post-operative day 2 following a total knee arthroplasty. The nurse notes that the client is reluctant to use the incentive spirometer. What is the nurse's priority action?
- ANotify the physician of the client's non-compliance通知醫師病人不配合
- BExplain the importance of the device in preventing pneumonia解釋該裝置在預防肺炎方面的重要性
- CDocument the client's refusal in the medical record在病歷中記錄病人拒絕行為
- DAssess the client's pain level on a scale of 0 to 10✓ 正解評估病人在 0 到 10 分量表上的疼痛程度
核心概念：解決妨礙預防性介入的障礙。術後病人拒絕呼吸練習，最常見的原因是疼痛（尤其在深呼吸時傷口會痛）。為何正確答案對：根據護理程序（Assessment first），必須先找出病人拒絕的原因。若疼痛控制不佳，衛教再多也沒效。為何其他選項錯：C 和 A 太早，尚未嘗試解決問題；B 雖重要，但在病人疼痛時效果有限。臨床思路：在 Reduction of Risk Potential 中，要落實預防措施（如預防肺塌陷），必須先移除執行障礙。妥善止痛後，病人配合度自然提升，這才符合以病人為中心的照護。
Core concept: addressing barriers to a preventive intervention. The most common reason a postoperative patient refuses respiratory exercises is pain (particularly because deep breathing aggravates the surgical wound). Why the correct answer is correct: According to the nursing process (assessment first), the reason for refusal must first be identified. If pain control is inadequate, education alone will be ineffective. Why the other options are incorrect: C and A are premature, as no attempt has been made to address the underlying issue; B is important, but is of limited effect while the patient is in pain. Clinical reasoning: Within the framework of Reduction of Risk Potential, implementing preventive measures (such as preventing atelectasis) requires first removing barriers to performance. With adequate analgesia, patient cooperation naturally improves, consistent with patient-centered care.
美國強調「疼痛是第五生命徵象」，護理師有較大的止痛藥物（PRN）給藥裁量權以促進復健；台灣臨床有時較強調忍痛或減少止痛藥使用，導致病人因痛而不敢深呼吸，增加肺部感染風險。