護理師正在為一名患有右肢深部靜脈栓塞（DVT）的病患制定護理計畫。計畫中應包含哪項處置？
The nurse is planning care for a client with deep vein thrombosis (DVT) of the right leg. Which intervention should be included in the care plan?
- AElevate the right leg above the level of the heart✓ 正解將右腿抬高至心臟水平以上
- BEncourage vigorous active range-of-motion exercises鼓勵劇烈的主動關節活動運動
- CApply a cold compress to the affected calf to reduce swelling對受影響的小腿應用冷敷以減輕腫脹
- DMassage the right leg twice daily to improve circulation每天按摩右腿兩次以改善循環
DVT 的護理重點在於促進靜脈回流、緩解腫脹並預防血栓脫落導致肺栓塞。抬高患肢（Elevate the leg）高於心臟水平可利用重力促進血液回流，有效減少水腫與疼痛。選項 C 是錯誤的，通常建議溫熱敷以促進血液循環而非冰敷。選項 D（按摩）是絕對禁忌，極可能導致血栓脫落。選項 B（劇烈運動）在急性期也應避免，通常建議墊高休息並在藥物穩定後才開始適度活動。此題旨在考察如何安全地促進循環並預防併發症。
Elevating the affected leg above heart level promotes venous return via gravity, effectively reducing edema and pain while preventing complications like pulmonary embolism. Massage and vigorous exercise are contraindicated in the acute phase due to the risk of dislodging the clot, whereas warm compresses are generally preferred over cold ones to enhance circulation.
美國 NCLEX 過去曾強調「嚴格臥床休息」，但最新的實務指引已轉向「一旦抗凝血劑達標即可早期活動」；台灣臨床目前仍多傾向讓 DVT 病患在入院初期維持相對靜止，並高度強調不可按摩。