— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位腳跟有第二級壓力性損傷的病人。應提供哪些照護？（選所有適合的）
A nurse is caring for a client with a stage 2 pressure injury on the heel. Which care should the nurse provide? (Select all that apply.)
- AKeep the wound clean and moist✓ 正解保持傷口清潔與濕潤
- BAvoid weight bearing on the heel✓ 正解避免腳跟承重
- CDebride necrotic tissue surgically外科清創壞死組織
- DApply a dressing to protect the wound✓ 正解敷蓋敷料以保護傷口
- EMassage the skin around the wound to increase circulation按摩傷口周圍皮膚以增加循環
— Explanation · 中文詳解 —
第二級壓傷涉及表皮至真皮層受損。治療重點為保持濕潤癒合環境（A）、減壓（B）與保護性敷料（D）。C 選項錯誤，第二級通常呈現潰瘍或水泡，不一定有壞死組織需手術清創；E 錯誤，按摩傷口周圍可能造成組織進一步破壞。
Care for a stage 2 pressure injury involves keeping the wound clean and moist to promote healing, offloading pressure from the heel, and applying a protective dressing. Surgical debridement is unnecessary for this stage, and massaging the area should be avoided as it can cause further tissue damage.
✦ 台美臨床差異
美國護理師常具備傷口造口護理師（WOCN）諮詢資源，台灣醫院則多設有傷口照護團隊或特別門診。