— 基本照護與舒適 · MEDIUM · SATA —
護理師協助病人進行個人衛生照護，下列哪些項目應納入照護計畫中？（選所有適合的）
A nurse is assisting a client with personal hygiene. Which of the following should be included in the care plan? (Select all that apply.)
- AClean eyes from the inner canthus to the outer canthus✓ 正解由內眥向外眥清潔眼睛
- BClean the perineum from the anal area toward the urethra由肛門區域向尿道方向清潔會陰部
- CUse warm water for bathing to prevent chilling✓ 正解使用溫水洗澡以防止發冷
- DEnsure the side rails are up after care✓ 正解照護結束後確保床欄拉起
- EAssess skin integrity during the bath✓ 正解在洗澡期間評估皮膚完整性
— Explanation · 中文詳解 —
個人衛生照護遵循「由乾淨到髒」及「預防感染」的原則。眼睛由內側向外側清潔，可避免碎屑流入淚管；使用溫水 bathing 可避免冷刺激造成身體不適；照護後將床欄拉起是防止跌倒的標準安全措施；沐浴時評估皮膚完整性是護理師監測壓瘡風險的機會。會陰部清潔必須由尿道向肛門，以防大腸桿菌進入尿道引起感染，故 B 選項錯誤。
Personal hygiene care should follow principles of cleanliness and infection prevention, such as cleaning eyes from the inner to outer canthus to protect the lacrimal duct. Using warm water prevents chilling, and assessing skin integrity during the bath helps identify potential pressure injuries. Side rails should be raised for safety, and perineal cleaning must proceed from front to back to avoid introducing fecal bacteria.