— 基本照護與舒適 · MEDIUM · MCQ —
護理師評估一位臥床 5 天的病人，發現左小腿有紅腫觸痛。下列哪項護理措施是禁忌的？
A nurse is assessing a client who has been on bed rest for 5 days. The nurse notes redness and tenderness on the left calf. Which nursing action is contraindicated?
- AMonitoring for shortness of breath監測是否有呼吸困難
- BMeasuring the calf circumference測量小腿周徑
- CMassaging the affected calf area✓ 正解按摩受影響的小腿部位
- DPlacing the limb in an elevated position將患肢抬高
— Explanation · 中文詳解 —
長期臥床出現單側小腿紅腫觸痛，應高度懷疑深層靜脈栓塞 (DVT)。按摩患部會增加血栓脫落並引發肺栓塞（PE）的風險，因此絕對禁止按摩。其他選項如測量周徑用於監測腫脹程度，抬高下肢有助於靜脈回流，觀察呼吸是為了及早發現 PE 跡象。
The client's symptoms suggest deep vein thrombosis (DVT), making massage of the affected leg strictly contraindicated due to the risk of dislodging the thrombus and causing a pulmonary embolism. Other actions like monitoring for respiratory distress, measuring calf circumference, and elevating the limb are appropriate interventions for managing DVT.
✦ 台美臨床差異
台灣臨床常見家屬習慣按摩以減輕疼痛，護理師需加強教導防止 DVT 的禁忌衛教。