— 基本照護與舒適 · EASY · MCQ —
護理師照顧長期臥床病人，哪項介入措施最能有效預防壓瘡發展？
A nurse is caring for a bedridden client. Which intervention best prevents the development of pressure injuries?
- AMassaging bony prominences按摩骨突處
- BKeeping the head of the bed elevated at 45 degrees保持床頭抬高 45 度
- CRepositioning the client every 2 hours✓ 正解每 2 小時為病人翻身
- DApplying moisturizing lotion to bony prominences在骨突處塗抹保濕乳液
— Explanation · 中文詳解 —
壓瘡（Pressure Injury）的預防核心在於減壓與避免組織長期缺血。長期臥床病人因缺乏活動，身體重量持續壓迫骨突處導致微血管阻塞、組織缺氧。每2小時翻身是臨床實證最有效減緩壓力累積的標準措施。護理思路應優先考慮改變受壓部位，以恢復局部血液循環。其他選項如按摩或使用靠墊，因可能造成剪力（Shearing force）或壓迫周邊血管，反而增加組織壞死風險。
Repositioning the client every 2 hours is the most effective evidence-based intervention to relieve prolonged pressure on tissues and prevent ischemia. Massaging bony prominences is contraindicated as it can cause tissue damage, while elevating the head of the bed excessively may increase shear forces.