— 降低風險 · EASY · MCQ —
護理師準備協助病人進行腰椎穿刺。下列何種護理行為是正確的？
A nurse is preparing a client for a lumbar puncture. Which nursing action is appropriate for the procedure?
- AAdminister a local anesthetic to the spinal cord對脊髓施用局部麻醉劑
- BPlace the client in a prone position將客戶置於俯臥位
- CEnsure the client remains NPO for 8 hours確保客戶禁食 8 小時
- DAssist the client into a side-lying fetal position✓ 正解協助客戶採取側臥胎兒姿勢
— Explanation · 中文詳解 —
腰椎穿刺需盡量張開椎間隙以便針頭進入，病人應側臥並保持胎兒蜷曲姿勢，將下巴貼近胸部，雙膝貼近腹部。此姿勢可拉開脊椎突間隙。B 錯誤（俯臥不對）；C 錯誤（不需空腹）；A 錯誤（麻醉僅限於局部皮膚，非脊髓）。
Assisting the client into a side-lying fetal position with knees drawn to the chest effectively widens the intervertebral spaces. This positioning facilitates needle insertion during a lumbar puncture by maximizing the gap between the vertebrae. Other positions or preparations, such as prone placement or NPO status, are not indicated for this procedure.
✦ 台美臨床差異
台美臨床在協助此檢查姿勢上並無顯著差異，重點均在於病人的舒適度與安全固定。