— 降低風險 · MEDIUM · SATA —
護理師準備執行肌肉注射。下列哪些步驟是正確的？（選所有適合的）
A nurse is preparing to administer an intramuscular injection to a client. Which actions are appropriate? (Select all that apply.)
- AAspirate for blood prior to injecting注射前回抽確認有無血液。
- BUse the Z-track method to minimize tissue irritation✓ 正解使用 Z 字法以減少組織刺激。
- CInject at a 45-degree angle以 45 度角注射。
- DSelect a needle of appropriate length based on muscle mass✓ 正解根據肌肉量選擇適當長度的針頭。
- EMassage the site vigorously after injection注射後用力按摩注射部位。
— Explanation · 中文詳解 —
肌肉注射標準：需依肌肉厚度選針長度；使用 Z 字型注入法（Z-track）可減少藥物回流與組織刺激。目前臨床對大多數 IM 注射已不再要求回抽（Aspiration）。注射角度應為 90 度而非 45 度；注射後不宜用力按摩，以免造成藥物過快吸收或組織損傷。
Needle length for intramuscular injections should be selected based on the client's muscle mass to ensure proper delivery. The Z-track method is recommended to minimize tissue irritation and prevent medication leakage into subcutaneous tissues. Current guidelines no longer recommend aspiration for most IM injections, and the needle should be inserted at a 90-degree angle without vigorous post-injection massage.
✦ 台美臨床差異
美國護理指引已不建議回抽，台灣部分臨床單位仍習慣回抽，但正逐步更新至國際標準。