— 安全與感染控制 · MEDIUM · SATA —
下列哪一項評估發現需要護理師立即介入以預防病人跌倒？（選所有適合的）
Which assessment finding requires the nurse to immediately intervene to prevent client falls? (Select all that apply.)
- AThe client's bed is in the lowest position病床處於最低位置
- BThe floor has spilled liquids near the client's bed✓ 正解病床附近地板上有潑灑的液體
- CThe call light is out of reach for the client✓ 正解呼叫鈴超出病人觸及範圍
- DThe client is wearing non-slip socks病人穿著防滑襪
- EThe bedside table with necessary items is positioned far away✓ 正解放置必要物品的床邊桌距離過遠
— Explanation · 中文詳解 —
跌倒預防的核心在於「環境安全」。選項 B（地面液體）、C（呼叫鈴無法觸及）與 E（日常用品放置過遠）皆是導致病人嘗試移動時發生跌倒的直接風險因子，護理師必須立即介入排除。病床低位（A）與防滑襪（D）屬於正確的預防措施，不需額外介入。臨床護理師需養成隨時掃描病室環境（Safety scan）的習慣，將預防跌倒納入日常照護流程。
Immediate intervention is required for environmental hazards such as spilled liquids, inaccessible call lights, and items placed too far away, as these increase fall risk. While a low bed position and non-slip socks are appropriate preventive measures, the nurse must promptly correct unsafe conditions like spills and unreachable equipment to ensure client safety.