— 安全與感染控制 · MEDIUM · MCQ —
護理師教導家屬約束帶使用原則，哪句話顯示家屬理解安全要求？
A nurse is teaching a family member about the use of restraints. Which statement indicates the family understands the safety requirements?
- AI will tie the restraint to the side rail of the bed我會將約束帶綁在床欄上
- BI will check the client's circulation every 2 hours我會每兩小時檢查一次病人的循環狀況
- CI will keep the restraint as tight as possible for security為了安全起見，我會將約束帶繫得越緊越好
- DI will release the restraint every 2 hours for assessment✓ 正解我會每兩小時鬆開約束帶以進行評估
— Explanation · 中文詳解 —
約束帶使用原則為每兩小時必須鬆開，評估皮膚完整性與循環狀況，並執行肢體活動。B 錯誤：循環評估通常要求每小時；A 錯誤：約束帶必須固定於床架（可動處），而非側欄（避免上升時壓傷）；C 錯誤：過緊會阻礙循環。
Restraints must be secured to the bed frame, not the side rails, to prevent injury if the rail is raised. They should be loose enough to allow two fingers to fit underneath, and circulation must be assessed hourly. Releasing the restraint every two hours is essential to assess skin integrity, neurovascular status, and promote mobility.
✦ 台美臨床差異
美國法規對約束限制非常嚴格，醫囑通常僅有效 4-24 小時；台灣臨床雖也有此規定，但執行面的落實程度有時會受人力限制而不同。