— 基本照護與舒適 · EASY · MCQ —
護理師協助術後病人首次由床移位至椅子，優先的護理措施為何？
A nurse is preparing to transfer a client from the bed to a chair for the first time after surgery. What is the priority nursing intervention?
- AEnsure the client is wearing non-slip footwear確保病人穿著防滑鞋
- BAssess the client's orthostatic blood pressure and dizziness✓ 正解評估病人的姿勢性血壓及頭暈情形
- CDangle the client at the bedside before standing在站立前讓病人雙腳垂於床緣
- DApply a gait belt around the client's waist在病人腰部繫上步態帶
— Explanation · 中文詳解 —
術後病人因長期臥床、手術麻醉及止痛藥物影響，自主神經調節功能暫時減弱，首次下床時極易發生姿勢性低血壓（Orthostatic Hypotension）。評估血壓與頭暈狀況是確保病人不會在轉移過程中暈厥的關鍵。護理師必須採取分階段活動策略，如先垂足於床邊（Dangling），觀察有無不適，再進行站立或轉移。
Postoperative patients are at high risk for orthostatic hypotension during their first transfer due to anesthesia and immobility. Assessing blood pressure and checking for dizziness determines physiological readiness and ensures safety before moving the client.