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基本照護與舒適 · EASY · MCQ

護理師協助臥床 3 天的病人進行首次下床活動,哪項護理措施能確保安全並優先執行?

A nurse is preparing to assist a client who has been on bed rest for 3 days with initial ambulation. Which intervention is the priority to ensure safety?

  • ACheck the client's blood pressure while lying down
    在個案躺臥時測量血壓
  • BAsk the client to take deep breaths while rising
    請個案在起身時深呼吸
  • CApply anti-embolism stockings before getting up
    在下床前穿戴抗栓塞襪
  • DDangle the client's legs on the side of the bed before standing✓ 正解
    在站立前讓個案雙腿垂於床緣
Explanation · 中文詳解

長期臥床者血管張力調節較差,由臥位改為站位易引發姿勢性低血壓。讓病人先在床邊坐起垂腿(dangling),可讓循環系統適應重力變化,減少暈厥或跌倒風險。BP 測量雖重要,但垂腿是臨床預防跌倒的首要物理動作。

When assisting a client who has been on bed rest with initial ambulation, dangling the legs at the side of the bed is the priority intervention to ensure safety. This position allows the cardiovascular system to adjust to gravity, effectively preventing orthostatic hypotension and reducing the risk of syncope or falls. While checking blood pressure is informative, physical adaptation through dangling is the essential first step before standing.

✦ 台美臨床差異

台美對於預防跌倒的流程相似,但美國更強調床邊的安全評估工具使用(如 Morse Fall Scale),台灣臨床則多由護理師觀察為主。

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