— 安全與感染控制 · MEDIUM · MCQ —
護理師照護使用軟質腕部約束的病人，下列哪項評估發現需要立即處理？
Which assessment finding by the nurse requires immediate intervention for a client in soft wrist restraints?
- AThe pulse is not palpable distal to the restraint✓ 正解約束帶遠端摸不到脈搏
- BThe client expresses frustration about the restraint個案對使用約束帶感到挫折
- CThe client is able to move their fingers個案能夠活動手指
- DThe restraint is tied to the bed frame約束帶綁在床架上
— Explanation · 中文詳解 —
使用約束裝置時，護理師必須定期檢查末梢循環。若摸不到脈搏，代表約束過緊導致血流受阻，可能造成組織缺血壞死，必須立即鬆開並重新評估，必要時聯繫醫師。維持末梢循環（脈搏、顏色、溫度、感覺）是約束照護中的首要安全考量。
When restraints are in use, the nurse must regularly check peripheral circulation. An impalpable pulse indicates that the restraint is too tight and is impeding blood flow, which can cause ischemic tissue necrosis. The restraint must be loosened and reassessed immediately, with notification of the provider as needed. Maintaining distal circulation (pulse, color, temperature, sensation) is the top safety priority in restraint care.
✦ 台美臨床差異
美國法規對約束要求極嚴格，需逐小時評估並頻繁由醫師評估是否解除；台灣則多由護理紀錄執行，較少頻繁更換醫囑。