— 安全與感染控制 · MEDIUM · MCQ —
護理師正在照護一名躁動且嘗試拔除中心靜脈導管的病人。護理師應優先採取哪項措施？
A nurse is caring for a client who is agitated and trying to pull out their central venous catheter. Which action should the nurse take first?
- AAssign a trained observer for one-on-one supervision.指派受訓人員進行一對一監護
- BRequest a prescription for a sedative medication.請求開立鎮靜劑處方
- CReorient the client and use de-escalation techniques.✓ 正解重新導向病人並使用減緩衝突技巧
- DApply soft wrist restraints immediately.立即施加軟質手腕約束帶
— Explanation · 中文詳解 —
面對躁動病人，優先採取「最少限制」（Least Restrictive）的干預。應先嘗試現實導向與溝通。若無效，A（一對一監視）是優於束縛的次選。A（約束）必須在所有非侵入性措施失敗後且有醫囑時才執行。B（鎮靜）同樣屬於化學束縛，非第一線首選。NCLEX 強調以人為本的循序介入。
The priority intervention for an agitated client attempting to remove a catheter is to use the least restrictive measures first. The nurse should reorient the client and employ de-escalation techniques to address agitation while preserving dignity, reserving restraints or sedatives for situations where these methods fail.
✦ 台美臨床差異
美國對「Least Restrictive」有法律上的嚴格要求；台灣臨床因護師比高，實務上常較快進入約束流程，但考題應選規範標準。