— 降低風險 · HARD · MCQ —
護理師照護一位接受持續傷口灌洗的病人，哪項評估發現需要立即干預？
A nurse is caring for a client with a continuous wound irrigation. Which assessment finding requires immediate intervention?
- AMild erythema at the wound edges傷口邊緣輕微發紅
- BGranulation tissue formation肉芽組織形成
- CSerosanguineous drainage漿液血性引流液
- DAbsence of drainage in the collection device✓ 正解收集裝置中無引流液
— Explanation · 中文詳解 —
持續傷口灌洗（Continuous wound irrigation）的目的是持續移除壞死組織、滲出液並保持傷口潔淨。若引流裝置中沒有引流量，這是一個危險的臨床訊號，暗示引流管路可能阻塞或系統故障。一旦發生，灌洗液將滯留在傷口腔室內，導致局部壓力升高、組織受壓缺血，甚至造成感染擴散，必須立即排查並處理。
Hand hygiene is the most effective and economical method for preventing healthcare-associated infections by breaking the chain of microbial transmission. While sterile gloves and gowns are reserved for specific procedures, routine assessments do not require them. Limiting visitors is not a primary prevention strategy when proper screening and hygiene protocols are followed.