— 安全與感染控制 · HARD · MCQ —
護理師觀察中心靜脈導管（CVC）部位，何種發現顯示可能有導管部位感染？
Which assessment finding in a client with a central venous catheter indicates a potential site infection?
- AThe catheter is slightly moved from the initial mark导管从初始标记处轻微移动
- BSmall amount of dried blood at the insertion site插入部位有少量干涸血迹
- CPurulent drainage and erythema✓ 正解脓性分泌物与红斑
- DClear serous fluid on the dressing敷料上有清澈浆液性液体
— Explanation · 中文詳解 —
中心靜脈導管（CVC）感染評估的核心在於識別局部發炎反應。臨床上，膿性分泌物（Purulent drainage）伴隨紅腫（Erythema）是細菌感染的典型指標（CLABSI 徵兆）。護理師在執行 CVC 照護時，應嚴格遵循無菌技術，並每日評估穿刺部位有無紅、腫、熱、痛或滲出物。若出現感染跡象，必須立即通報醫師，並可能需要採集導管尖端及血液培養以進行病原體檢測。
Purulent drainage and erythema at the insertion site are classic indicators of a local infection, such as a CLABSI. While minor dried blood or clear serous fluid may be expected, and catheter migration is a mechanical issue, pus and redness require immediate medical evaluation.