— 照護管理 · MEDIUM · MCQ —
護理師照護一位有癲癇病史，因跌倒入院的病人，病人現已清醒且定向力正常。應執行哪項安全措施最重要？
A nurse is caring for a client with a history of seizures who is admitted after a fall. The client is now alert and oriented. Which safety measure is MOST important to implement?
- AKeep the bed in the lowest position將病床調整至最低位置
- BHave seizure precautions readily available (e.g., oxygen, suction)✓ 正解隨時備妥癲癇防護措施（例如：氧氣、抽吸設備）
- CPad the side rails在床欄上鋪設軟墊
- DEnsure the client wears a medical alert bracelet確保病人佩戴醫療警示手環
— Explanation · 中文詳解 —
癲癇（seizure）病人即使目前意識清醒，仍具備隨時發作的潛在風險。NCLEX 考試重點在於病人安全（Safety）與準備（Preparedness）。若病人發生癲癇，呼吸道通暢（ABC 原則）是首要任務，因此備妥氧氣與抽痰設備是維護病人生命安全最核心的措施。其他選項雖然有助於環境安全，但不如針對緊急氣道管理設備的準備來得緊急且關鍵。
Although the client is currently alert, the history of seizures indicates a persistent risk for sudden episodes where airway patency is critical. Having seizure precautions, including oxygen and suction equipment, readily available ensures the nurse can immediately manage potential respiratory compromise if a seizure occurs.