— 基本照護與舒適 · EASY · MCQ —
一位有高血壓病史的病人正在準備進行身體評估。護理師應使用哪種技巧以確保血壓測量準確？
A nurse is preparing a client with a history of hypertension for a physical assessment. Which technique should the nurse use to ensure an accurate blood pressure reading?
- ASelect a cuff that covers the entire upper arm選擇覆蓋整個上臂的袖帶
- BPosition the arm above the level of the heart將手臂置於心臟水平以上
- CEnsure the client's feet are flat on the floor✓ 正解確保病人的雙腳平放在地板上
- DHave the client cross their legs to stabilize the posture讓病人交叉雙腿以穩定姿勢
— Explanation · 中文詳解 —
準確的血壓測量需要病人處於放鬆且標準化的姿勢，否則生理因素會造成讀數失真。AHA（American Heart Association）建議測量前病人應安靜休息 5 分鐘，雙腳平放於地面、不可交叉雙腿、手臂支撐於心臟水平、袖帶尺寸需覆蓋上臂周徑 80% 並包覆上臂約三分之二長度。雙腳平放可避免肌肉緊張與靜脈回流改變所造成的血壓上升，是確保讀數準確的基本姿勢條件，故為正解。
To ensure an accurate blood pressure reading, the client’s feet should be flat on the floor to prevent increased muscle tension and false elevation of pressure. The arm must be supported at heart level, and crossing the legs should be avoided as it can artificially raise systolic readings.