護理師照護一位接受骨骼牽引的病人。下列哪項評估結果最為優先，應立即通報醫療提供者？
The nurse is caring for a client in skeletal traction. Which assessment finding is the priority and should be reported to the provider?
- AThe client reports a pain level of 4 out of 10個案報告疼痛程度為十分之四
- BSmall amount of clear serous drainage at the pin sites釘道處有少量清澈漿液性滲出
- CThe weights are resting on the floor✓ 正解重錘放置在地面上
- DMuscle spasms in the affected extremity患肢肌肉痙攣
本題考核骨骼牽引的安全管理原則。牽引的主要目的是維持骨折對位、減輕痙攣或固定肢體。關鍵安全原則是「牽引重錘必須懸空（Weights must hang freely）」，不得接觸地面或床架。如果重錘接觸地面（選項 C），牽引力就會完全喪失，導致骨折處移位或劇烈疼痛，這是立即的安全失效。選項 B（少量清澈漿液滲出）是正常初期癒合表現；選項 A 的中度疼痛可透過藥物處置；選項 D 的肌肉痙攣是牽引常見的副作用（雖需處理但非首要安全風險）。護理師應立即調整病人體位或與醫師聯繫以恢復有效牽引。
The priority finding is that the weights are resting on the floor because this negates the therapeutic effect of traction, potentially causing fracture misalignment and injury. While moderate pain, serous drainage, and muscle spasms are common or manageable findings, loss of traction is a critical safety failure requiring immediate correction.
美國 NCLEX 考試極度強調「Maintenance of Traction」的物理完整性。台灣護理實務中，護理師常會自行調整病人體位使重錘懸空，但在考題邏輯中，這被視為必須立即識別並排除的關鍵安全問題。