— 基本照護與舒適 · EASY · SATA —
護理師照顧一位有跌倒史的病人。應實施哪些安全措施？（選所有適合的）
A nurse is caring for a client with a history of falls. Which safety measures should be implemented? (Select all that apply.)
- AKeep the bed in the lowest position.✓ 正解將病床調整至最低位置。
- BPlace a bedside commode near the bed.✓ 正解在床邊放置便盆椅。
- CLock the wheels on the bed and wheelchair.✓ 正解鎖定病床和輪椅的輪子。
- DKeep all four side rails in the up position.將所有四個床欄拉起。
- EEnsure adequate lighting in the room.✓ 正解確保房間有充足的照明。
— Explanation · 中文詳解 —
防跌措施包括：床位降至最低（A）、提供床邊便器以減少行走（B）、鎖住輪子防止滑動（C）及充足照明（E）。拉起所有四面床欄（D）被視為「約束（Restraint）」，可能導致病人試圖翻越而跌得更重，通常只建議拉起兩側近頭端的床欄。
Fall prevention strategies include keeping the bed in the lowest position to minimize injury, providing a bedside commode to reduce ambulation distance, locking wheels to prevent movement during transfers, and ensuring adequate lighting for safe navigation. Raising all four side rails is contraindicated as it constitutes a restraint and may encourage clients to climb over, increasing fall severity.
✦ 台美臨床差異
美國對「Restraint-free environment」有極嚴格要求；台灣近年也在推動減少床欄使用，但家屬接受度仍待加強。