— 基本照護與舒適 · MEDIUM · MCQ —
護理師準備將病人從床位轉移至椅子。優先採取的護理措施為何？
A nurse is preparing to transfer a client from the bed to a chair. What is the priority nursing action?
- AAssess the client's ability to bear weight and follow instructions✓ 正解評估個案負重及遵循指示的能力
- BApply a gait belt around the client's waist在個案腰部繫上移位腰帶
- CLock the wheels of the bed and the chair鎖定床和椅子的輪子
- DPlace the chair at a 90-degree angle to the bed將椅子放置在與床呈 90 度角的位置
— Explanation · 中文詳解 —
病人安全評估是所有轉移活動的第一步。在採取物理保護措施（如腰帶）前，必須先評估病人的認知狀況（是否聽得懂指示）、肌力與患肢負重限制，這決定了轉移方式（一人/二人/輔具），避免造成病人跌倒或醫護人員受傷。
The priority nursing action before transferring a client is to assess their ability to bear weight and follow instructions to ensure safety. This assessment determines the appropriate transfer technique and level of assistance needed, preventing falls or injury to both the client and staff. Physical aids like gait belts and environmental preparations such as locking wheels are important but secondary to evaluating the client's physical capabilities.
✦ 台美臨床差異
美國非常強調移位前的風險評估量表（如 Morse Fall Scale）；台灣則多依臨床經驗判斷。