— 降低風險 · EASY · MCQ —
護理師為有壓瘡風險的病人擬定護理計畫，下列哪項預防皮膚損傷措施最有效？
A nurse is planning care for a client who has a risk for pressure ulcers. Which nursing intervention is most effective for preventing skin breakdown?
- AApplying powder to the skin在皮膚上塗抹爽身粉
- BMassage bony prominences regularly定期按摩骨突處
- CRepositioning the client every 2 hours✓ 正解每2小時為病人翻身
- DElevating the head of the bed to 45 degrees將床頭抬高45度
— Explanation · 中文詳解 —
壓瘡預防最核心的護理介入是定期翻身，以減輕受壓部位的組織壓力。A 錯誤：粉末可能導致皮膚刺激或乾燥。B 錯誤：按摩骨突處會增加組織受損風險。D 錯誤：床頭抬高過度會增加剪力（shearing force），若需抬高建議不要超過 30 度。
Repositioning the client every 2 hours is the most effective intervention because it relieves prolonged pressure on tissues, which is the primary cause of pressure ulcer formation. Other options are incorrect because massaging bony prominences can damage underlying capillaries, powders may cause irritation, and elevating the head of the bed excessively increases shear forces.
✦ 台美臨床差異
美國護理界對於壓瘡預防有極強的實證規範（如 Braden Scale 應用）；台灣目前也廣泛應用此評估量表與預防措施。