— 降低風險 · MEDIUM · MCQ —
護理師準備協助病人執行腰椎穿刺，哪項護理行動對於預防中樞神經感染最重要？
A nurse is preparing a client for a lumbar puncture. Which action must the nurse prioritize to prevent infection of the CNS?
- ALabel all collected specimens immediately立即標記所有收集的檢體
- BMonitor vital signs before and after the procedure監測術前和術後的生命徵象
- CEnsure the client maintains a lateral recumbent position確保病人維持側臥位
- DMaintain strict sterile technique during the procedure✓ 正解在手術期間維持嚴格的無菌技術
— Explanation · 中文詳解 —
腰椎穿刺涉及穿透硬脊膜進入蛛網膜下腔，這是無菌體腔。任何微生物的侵入都可能引發嚴重的細菌性腦膜炎，因此在操作過程中執行嚴格的無菌技術，包括無菌手套、消毒皮膚區域以及保護穿刺部位，是防範感染發生的關鍵。
A lumbar puncture involves penetrating the dura mater to access the subarachnoid space, which is a sterile environment vulnerable to serious infections like bacterial meningitis. Maintaining strict sterile technique throughout the procedure is the highest priority to prevent the introduction of pathogens into the central nervous system. While other actions support identification or stability, sterility directly addresses infection prevention.
✦ 台美臨床差異
台灣通常由醫師單獨執行，護理師主要負責擺位與監測；美國則常有護理師全程協助 sterile field 維持。