— 基本照護與舒適 · MEDIUM · MCQ —
病人抱怨右小腿疼痛，護理師觀察到腫脹與紅斑。下列何者為優先行動？
A client complains of pain in the right calf. The nurse observes swelling and erythema. What is the priority action?
- AApply a warm compress to the area在患處施加溫敷
- BEncourage the client to ambulate to prevent stasis鼓勵病人行走以防止血液淤滯
- CMassage the calf to improve circulation按摩小腿以改善循環
- DMaintain bed rest and notify the provider✓ 正解維持臥床休息並通知醫師
— Explanation · 中文詳解 —
右小腿腫脹、紅斑及疼痛為深層靜脈栓塞（Deep Vein Thrombosis, DVT）的典型臨床表現。護理師的優先處置目標是防止血栓脫落（Dislodgment），以免引發致命的肺栓塞（Pulmonary Embolism, PE）。因此，必須採取絕對臥床（Strict bed rest）並通知醫師進行檢查，嚴禁按摩患部。
The priority action for a client with signs of DVT is to maintain bed rest to prevent thrombus dislodgement and immediately notify the provider for diagnostic evaluation. Activities like massage or ambulation are contraindicated as they increase the risk of pulmonary embolism.