— 降低風險 · EASY · MCQ —
一位病人剛進行腰椎穿刺。為降低併發症風險，護理師應採取何種優先措施？
A nurse is caring for a client who just underwent a lumbar puncture. Which action is the priority to reduce the risk of complications?
- ARestrict oral fluid intake for the next 8 hours未來 8 小時限制經口攝取液體
- BMaintain the client in a flat, supine position for several hours✓ 正解讓病人保持平躺仰臥姿勢數小時
- CEncourage the client to ambulate immediately to prevent DVT鼓勵病人立即行走以預防深層靜脈血栓
- DApply a hot pack to the lumbar puncture site在腰椎穿刺部位敷熱敷包
— Explanation · 中文詳解 —
腰椎穿刺（Lumbar puncture）後，最常見的併發症是「穿刺後頭痛（Post-dural puncture headache）」，這是因為腦脊髓液（CSF）持續外漏，導致顱內壓力改變所致。平躺姿勢可減少腦脊髓液從穿刺孔流出的壓力梯度，有助於穿刺部位的癒合。護理師應鼓勵病人攝取水分，以促進腦脊髓液的再生成，進而維持顱內壓力平衡。
Maintaining the client in a flat, supine position for several hours after a lumbar puncture helps minimize the risk of a post-dural puncture headache by reducing cerebrospinal fluid leakage. This positioning decreases pressure gradients at the puncture site, facilitating healing and preventing intracranial pressure changes.