— 降低風險 · MEDIUM · MCQ —
護理師為病人準備腰椎穿刺檢查，下列哪項行為對確保病人安全至關重要？
A nurse is preparing a client for a lumbar puncture. Which action is essential for the nurse to perform to ensure client safety?
- AAdminister a sedative prior to the procedure to prevent movement在手術前給予鎮靜劑以防止移動
- BEnsure the client remains in a side-lying position with knees flexed✓ 正解確保病人保持側臥位並屈膝
- CInstruct the client to remain supine for 24 hours post-procedure指示病人在手術後平躺 24 小時
- DObtain written informed consent from the client's family member取得病人家人的書面知情同意
— Explanation · 中文詳解 —
腰椎穿刺時，將病人置於側臥位且膝蓋彎曲胸前，可打開脊椎間隙，有利於針頭進入且減少組織損傷。B 傳統需平躺，現代實證顯示不一定需維持 24 小時；C 未經醫師指示不隨意給藥；D 原則上需本人簽署同意書，除非意識不清。
Positioning the client in a side-lying posture with knees flexed toward the chest maximizes the intervertebral spaces, facilitating safe needle insertion into the subarachnoid space.
✦ 台美臨床差異
美國護理師在確認 Consent 方面有嚴格的查核角色，台灣護理師較常協助醫護解釋。