— 降低風險 · HARD · MCQ —
護理師照護一位裝有中心靜脈導管（CVC）的病人。發現導管不慎脫出。優先行動為何？
A nurse is caring for a client with a central venous catheter (CVC). The nurse notes that the CVC has been accidentally dislodged. What is the priority action?
- ANotify the provider通知醫師
- BAdminister oxygen給予氧氣
- CReinsert the catheter重新插入導管
- DApply pressure to the insertion site✓ 正解在插入口施加壓力
— Explanation · 中文詳解 —
CVC 脫出後，首要危險是空氣進入靜脈導致氣栓（Air embolism）或出血。護理師必須立刻以無菌紗布對傷口施加壓力以止血並封閉通道。完成止血與封閉後，再採取後續動作如通知醫師，絕對不可嘗試自行重新插入。
After a CVC dislodges, the primary danger is air entering the vein and causing an air embolism, or hemorrhage. The nurse must immediately apply pressure to the insertion site with sterile gauze to control bleeding and seal the tract. Only after hemostasis and closure are achieved should subsequent actions, such as notifying the provider, be taken; the nurse must never attempt to reinsert the catheter.
✦ 台美臨床差異
兩國對中心靜脈導管脫出的護理共識高度一致，均強調防氣栓與止血。