— 基本照護與舒適 · EASY · MCQ —
護理師協助術後首次下床活動的活動受限病人。哪項是優先護理措施？
A nurse is assisting a client with limited mobility to get out of bed for the first time after surgery. What is the priority nursing action?
- ADangle the client's legs at the bedside first✓ 正解首先讓病人雙腳懸垂於床緣
- BCheck the client's blood pressure while standing在病人站立時測量血壓
- CApply a gait belt to the client's waist在病人腰部綁上步態帶
- DRequest assistance from a second nurse請求第二位護理師協助
— Explanation · 中文詳解 —
術後首次下床活動，最大的安全隱憂是姿勢性低血壓（Orthostatic hypotension）導致的暈厥與跌倒。麻醉藥物與長期臥床會降低血管收縮反射。採取漸進式體位轉換（如先坐於床緣 dangle）能讓血液重新分配，觀察病人有無頭暈或心跳加速，確保其對重力變化有足夠的生理適應，是確保安全的核心步驟。
Dangling the client's legs at the bedside allows the cardiovascular system to adjust to positional changes, thereby preventing orthostatic hypotension and reducing the risk of syncope or falls. This step ensures physiological stability before the client attempts to stand or walk.