護理師照護一位股骨骨折並接受骨骼牽引的病人。哪項評估發現需要立即介入？
The nurse is caring for a client with a fractured femur who is in skeletal traction. Which assessment finding requires immediate intervention?
- AThe weights are resting on the floor.✓ 正解重量懸掛在地板上
- BMuscle spasms in the affected leg.患側腿部肌肉痙攣
- CThe client reports pain at the fracture site.客戶報告骨折部位疼痛
- DSerosanguineous drainage at the pin site.釘道處有漿血性滲出物
骨骼牽引的核心原則是維持持續且穩定的牽引力，以達成骨折端的對齊與固定。牽引重量（Weights）必須「懸空」（Hang freely），絕對不能接觸地面。如果重量著地，牽引力就會消失，這可能導致骨折處移位、疼痛加劇或肌肉損傷。這是基本的安全監測任務。少量淡血水滲出（D）在針孔處是常見的；疼痛（C）與肌肉痙攣（B）雖然需要處理，但往往是牽引力失效後的結果，或是骨折初期的常見症狀。護理師必須確保物理環境的正確性，這是減少骨科病人併發症（如畸形癒合）的基礎風險管理工作。
The weights in skeletal traction must hang freely to maintain the prescribed traction force and ensure proper bone alignment. If the weights rest on the floor, the traction is lost, which can lead to fracture displacement, increased pain, and muscle injury, requiring immediate correction. While pain, muscle spasms, and slight serosanguineous drainage are common or expected findings, loss of traction is a critical safety issue.
美國 NCLEX 非常強調「護理師不可擅自移除牽引重量」的原則；台灣臨床上，護理師除維持牽引外，更強調預防因長期臥床產生的壓瘡與深部靜脈血栓 (DVT)。