護理師照護一位長期臥床病人，發現骶骨有壓瘡。下列哪項措施最能有效預防皮膚進一步潰瘍？
A nurse is caring for an immobile client who has developed a pressure ulcer on the sacrum. Which intervention is most effective at preventing further skin breakdown?
- AApplying a heat lamp to the area對該區域應用熱燈
- BMassaging the bony prominences按摩骨突處
- CRepositioning the client every 2 hours✓ 正解每 2 小時為病人更換姿勢
- DMaintaining a dry environment by using talcum powder使用滑石粉維持環境乾燥
壓瘡（Pressure ulcer）的預防核心在於移除導致組織缺血的持續壓力與剪力（Shearing force）。長期臥床病人若姿勢固定，軟組織會因微血管灌流受阻而缺氧壞死。每 2 小時更換體位能恢復受壓部位的血流供應。臨床上，除翻身外，還應評估使用減壓輔具（如氣墊床）並維持營養狀況，這是預防皮膚破損的最有效策略。
Repositioning the client every 2 hours is the most effective intervention to relieve capillary pressure on bony prominences and restore blood flow, thereby preventing further skin breakdown. Massage, heat lamps, and talcum powder are contraindicated as they can cause tissue damage, burns, or skin irritation.
美國臨床護理（如 Braden Scale 應用）極度強調翻身紀錄（Turning schedule）的落實，並常結合多學科團隊（Wound Care Nurse）進行評估。台灣部分護理機構可能因人力配置較緊，翻身頻率執行不一，但 NCLEX 考試中，標準答案永遠是每 2 小時。