— 生理適應 · MEDIUM · SATA —
一位右小腿深部靜脈栓塞 (DVT) 病人的護理計畫中應包含哪些干預？（選所有適合的）
A client is admitted with deep vein thrombosis (DVT) in the right calf. Which nursing interventions should be included in the care plan? (Select all that apply.)
- AApply sequential compression devices (SCDs) to both legs雙腿均穿戴順序性加壓裝置（SCDs）
- BElevate the right leg above the level of the heart✓ 正解將右腿抬高至高於心臟水平
- CMassaging the right calf to improve circulation按摩右小腿以改善循環
- DMonitor for symptoms of pulmonary embolism✓ 正解監測肺栓塞症狀
- EAdminister anticoagulant therapy as prescribed✓ 正解依醫囑給予抗凝血治療
— Explanation · 中文詳解 —
DVT 護理重點：抬高患肢促進回流（B）、監測致命併發症肺栓塞（D）、給予抗凝血藥（E）。SCDs（A）只能用於預防，一旦確診 DVT，患肢禁用 SCDs 以防血栓脫落。絕對禁止按摩患肢（C），以免血栓游走。
Nursing care for deep vein thrombosis includes elevating the affected limb to promote venous return and administering prescribed anticoagulants to prevent clot extension. The nurse must also monitor closely for signs of pulmonary embolism, while avoiding massage or sequential compression devices on the affected leg to prevent thrombus dislodgement.
✦ 台美臨床差異
美國 NCLEX 強烈考查禁忌（Contraindications），如 DVT 禁用按摩與 SCDs。