— 降低風險 · MEDIUM · SATA —
護理師照護一位接受身體約束的病人。哪些行動是確保安全所必需的？（選所有適合的）
A nurse is caring for a client who is in restraints. Which actions are necessary to ensure safety? (Select all that apply.)
- AAssess the restraint site every hour✓ 正解每小時評估約束部位
- BEnsure the restraint is tied to a movable part of the bed frame確保約束帶綁在床架的可移動部分
- CProvide range-of-motion exercises every 2 hours✓ 正解每兩小時提供關節活動範圍運動
- DCheck capillary refill and pulses distal to the restraint✓ 正解檢查約束處遠端的毛細血管再充盈時間與脈搏
- ERelease restraints briefly to provide toileting/nutrition✓ 正解短暫解除約束以提供如廁/營養需求
— Explanation · 中文詳解 —
約束照護重點：定時評估約束處（通常每小時）、檢查遠端循環（脈搏、血液回流）、定期活動關節以免僵硬、定期釋放約束以提供如廁與營養。約束帶必須綁在床架的「固定處」，絕不可綁在「可活動部分」（如床欄），以防受傷。
The nurse must intervene to remove the N95 respirator from the client and replace it with a standard surgical mask, as this is the CDC-recommended practice for transporting contagious airborne patients. Surgical masks effectively contain respiratory droplets from the patient, while N95s are reserved for healthcare providers to protect against inhalation.
✦ 台美臨床差異
美台對於身體約束的規範皆非常嚴格，美國更強調「最少限制原則」，台灣醫院目前亦積極推動減少約束（Reduce restraint）。