— 安全與感染控制 · EASY · SATA —
護理師照護一位跌倒高風險病人，下列哪些護理措施適合確保其安全？（選所有適合的）
A nurse is caring for a client who is at high risk for falls. Which nursing actions are appropriate to ensure safety? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace the call light within the client's reach✓ 正解將呼叫鈴放置在病人可觸及之處
- CEncourage the client to get up independently at night鼓勵病人在夜間獨立起床
- DEnsure the floor is free of clutter✓ 正解確保地面無雜物
- EUtilize non-slip footwear when the client ambulates✓ 正解病人行走時使用防滑鞋
— Explanation · 中文詳解 —
防跌計畫的核心在於「預防」與「環境控制」。正確的防跌策略應包含：維持床位低位、確保呼叫鈴在手邊（減少病人自行起身的需求）、移除地毯等阻礙物，以及使用防滑鞋具。鼓勵病人獨立下床若未經過評估與訓練，極易造成意外，特別是在夜間視線不佳時。護理師的角色在於提供一個安全的物理環境，並透過教育提升病人的安全意識。
Fall prevention strategies include keeping the bed in the lowest position, ensuring the call light is within reach, removing environmental clutter, and using non-slip footwear to enhance stability. Encouraging independent ambulation without assistance increases fall risk, so nurses must provide a safe environment and assist clients as needed.