— 降低風險 · MEDIUM · SATA —
護理師照護一位疑似深層靜脈栓塞（DVT）的病人。下列哪些護理措施是禁忌的？（選所有適合的）
A nurse is caring for a client with a suspected deep vein thrombosis (DVT). Which of the following nursing interventions is contraindicated? (Select all that apply.)
- AApply warm compresses to the affected area對患處施加溫熱敷
- BMassage the affected lower extremity✓ 正解按摩受影響的下肢
- CElevate the affected extremity抬高患肢
- DAmbulate the client to promote blood flow✓ 正解讓病人下床行走以促進血液循環
- EApply compression stockings as ordered依醫囑穿戴彈性襪
— Explanation · 中文詳解 —
DVT 病人嚴禁按摩患肢，因物理施壓可能導致血栓脫落引發肺栓塞。絕對禁止下床行走（Ambulation）直到抗凝血治療生效。A 與 C 是改善症狀的護理，E 為預防栓塞惡化的治療手段，但在急性診斷階段需配合醫囑。
Massaging the affected extremity is strictly contraindicated in suspected deep vein thrombosis (DVT) because it can dislodge the thrombus and cause a life-threatening pulmonary embolism. Ambulation is also restricted until anticoagulant therapy is effective to prevent clot migration, whereas elevation and warm compresses are safe interventions to reduce edema and pain.
✦ 台美臨床差異
在美國護理師常需負責執行下肢超音波檢查的準備及後續監測；台灣臨床上則多由放射科醫師或技術員操作，護理師專注於給藥與觀察。