— 降低風險 · MEDIUM · MCQ —
護理師準備協助病人進行腰椎穿刺。下列哪項護理行動對於降低潛在併發症風險至關重要？
A nurse is preparing a client for a lumbar puncture. Which action must the nurse prioritize to reduce the risk of potential complications?
- AVerify the presence of a witness for the procedure確認有見證人在場
- BEnsure the client remains NPO for 8 hours確保病人禁食 8 小時
- CCheck the client's coagulation profile✓ 正解檢查病人的凝血功能
- DAdminister a prophylactic antibiotic給予預防性抗生素
— Explanation · 中文詳解 —
腰椎穿刺屬於侵入性檢查，最危險的併發症之一是硬脊膜外血腫或出血。若病人凝血功能異常（如血小板過低或 INR 升高），穿刺處容易導致無法控制的出血，壓迫脊髓造成神經損傷。因此，護理師在檢查前確認相關檢驗數值是維護病人安全的第一道防線。
Checking the client's coagulation profile is the priority to prevent hemorrhagic complications, such as epidural hematoma, which can compress the spinal cord. Since a lumbar puncture is invasive, verifying normal clotting function is essential before the procedure to ensure patient safety.
✦ 台美臨床差異
台灣通常由醫師在檢查前親自審查檢驗數值；美國則仰賴護理師在術前核對清單中確實執行並簽核。