護理師照護一位意識混亂且試圖拔除中心靜脈導管的病人。護理師應優先執行哪項措施？
The nurse is caring for a confused client who is attempting to pull out their central venous catheter. Which intervention should the nurse implement first?
- AApply soft wrist restraints to both arms雙臂使用軟質手腕約束帶
- BPlace the client in a room close to the nurse's station將病人安置在護理站附近的房間
- CRequest a family member or sitter to stay with the client✓ 正解請求家屬或看護者陪伴病人
- DAdminister a prescribed PRN sedative給予處方之備用鎮靜劑
本題考點在於「限制（Restraints）」使用的階層式原則。護理倫理與安全標準要求應先使用「最少限制（Least restrictive）」的方法。當病人出現危及管路安全的行為時，物理性限制（如腕式約束帶）應是最後手段。優先考量包括：持續觀察、分散注意力、加強陪伴等。讓家屬或專人（Sitter）陪伴（選項 C）既能即時阻止病人拔管，又不限制其肢體活動。選項 B 雖有助於觀察，但無法直接阻止手部動作；選項 A 是物理約束，選項 D 是化學約束，皆應在非侵入性方法無效後才考慮。臨床思維應始終以病人自主權與安全平衡為前提。
The nurse should first request a family member or sitter to stay with the client, as this provides constant observation and redirection using the least restrictive method. Physical or chemical restraints are considered last resorts and should only be implemented if less restrictive interventions fail to ensure safety.
美國對於 Restraint-Free 環境的要求極高，醫院必須記錄嘗試過的所有替代方案。台灣在約束的使用上相對較為普遍，且有時會將其視為常規預防措施，但在 NCLEX 考試中，必須嚴格遵守「最後手段」原則。