— 基本照護與舒適 · EASY · MCQ —
護理師協助一位長者進行晨間護理，哪項評估結果需要立即採取護理措施？
A nurse is assisting an elderly client with morning hygiene. Which assessment finding requires immediate nursing intervention?
- APresence of stage 1 pressure injury on the heel腳跟出現第一期壓瘡
- BCapillary refill time of 5 seconds in the big toe✓ 正解大腳趾的毛細血管再充盈時間為 5 秒
- CClient reports a pain level of 3 out of 10病人報告疼痛程度為 10 分中的 3 分
- DDry, flaky skin on the lower extremities下肢皮膚乾燥脫屑
— Explanation · 中文詳解 —
微血管回充時間（CRT）超過 3 秒反映周邊血液循環不佳，代表末梢灌流不足，可能出現動脈阻塞或休克，屬於需優先處理的生理指標。第一級壓瘡雖需護理，但不若循環受損危及組織活性；疼痛程度 3 分尚在可控範圍；乾燥皮膚則可透過乳液緩解。
A capillary refill time of 5 seconds indicates impaired peripheral perfusion, suggesting potential arterial occlusion or shock, which requires immediate nursing intervention. While stage 1 pressure injuries and dry skin need attention, they are not acute emergencies compared to compromised circulation. Mild pain levels can be managed after addressing critical physiological deficits.
✦ 台美臨床差異
台美護理師皆高度重視 CRT，但美國護理師常需更主動依此結果聯繫專科醫生會診。