— 照護管理 · HARD · SATA —
護理師在執行階段（Implementation）應執行哪些護理措施？（選所有適合的）
Which actions should the nurse perform during the implementation phase of the nursing process? (Select all that apply.)
- AProviding direct client care, such as wound dressing✓ 正解提供直接病人照護，例如傷口換藥
- BPrioritizing nursing diagnoses for the care plan為護理計畫優先排序護理診斷
- CAdministering medications as prescribed✓ 正解依醫囑給藥
- DDocumenting nursing interventions performed✓ 正解紀錄已執行的護理介入措施
- EEvaluating the effectiveness of nursing interventions評估護理介入措施的成效
— Explanation · 中文詳解 —
護理程序（Nursing process）分為評估、診斷、計畫、執行、評值。執行階段（Implementation）是將計畫付諸行動的過程，包括直接照護（如換藥）、給藥、執行醫囑與完整紀錄執行內容。優先排序診斷屬計畫階段；評估療效屬評值階段。護理師在此階段需確保所有措施皆安全、正確且及時完成，並做好詳細護理紀錄。
The implementation phase involves executing the care plan through direct client care, administering medications, and documenting interventions performed. Prioritizing diagnoses belongs to the planning phase, while evaluating outcomes occurs during the evaluation phase.