護理師督導一位正在照護癲癇病史病人的護理助理(UAP),下列哪項 UAP 的行為需要護理師立即介入?
A nurse is supervising an unlicensed assistive personnel (UAP) who is providing care for a client with a history of seizures. Which action by the UAP requires immediate intervention by the nurse?
- AAttempting to insert a tongue blade into the client's mouth✓ 正解試圖將壓舌板插入病人口中
- BLoosening the client's clothing around the neck鬆開病人頸部的緊身衣物
- CPlacing the client in a side-lying position during a seizure在癲癇發作期間將病人置於側臥姿勢
- DMoving furniture away from the client during a seizure在癲癇發作期間將家具移開
癲癇發作時絕對不可強行放入任何物品至病人口中,這可能導致牙齒碎裂、呼吸道阻塞或吸入性肺炎。正確原則為保護頭部、側臥以利分泌物引流,並觀察發作時間。UAP 執行侵入性或具風險的操作屬於嚴重失誤,需立即阻止。
Inserting any object, such as a tongue blade, into the mouth during a seizure is strictly prohibited as it can cause dental trauma, gum lacerations, or airway obstruction. The nurse must immediately intervene to stop this unsafe practice. Correct actions include loosening restrictive clothing, placing the client in a side-lying position to drain secretions, and clearing the surrounding area to prevent physical injury.
美台護理教育均嚴格禁止在癲癇發作時放置壓舌板。美國醫院更強調 UAP 的職責邊界限制,台灣醫院則多透過標準作業程序加強教育。