— 降低風險 · EASY · MCQ —
護理師準備協助病人進行腰椎穿刺，下列哪項措施最為優先？
A nurse is preparing a client for a lumbar puncture. Which action is priority for the nurse to perform?
- AObtaining informed consent from the client✓ 正解取得病人的知情同意
- BPositioning the client in a prone position將病人置於俯臥姿勢
- CAdministering the prescribed prophylactic antibiotic給予處方的預防性抗生素
- DEnsuring the client remains NPO for 8 hours確保病人禁食 8 小時
— Explanation · 中文詳解 —
腰椎穿刺屬於侵入性檢查，取得知情同意是執行前最重要的法律與倫理步驟。C 並非例行常規；D 腰穿通常不需禁食；B 正確姿勢應為側臥屈膝（胎兒姿勢），而非俯臥。護理師需確認醫師已向病人解釋風險後才進行協助。
Obtaining informed consent is the priority action because a lumbar puncture is an invasive procedure requiring legal verification of patient understanding. The client should be positioned in a side-lying fetal position, not prone, and NPO status is generally not required for this procedure.
✦ 台美臨床差異
美台兩地在法規上均嚴格要求執行侵入性檢查前須完成知情同意。