— 基本照護與舒適 · MEDIUM · MCQ —
一位臥床病人有壓力性損傷風險，下列哪項護理措施對預防皮膚破損最有效？
A client on bed rest is at risk for developing pressure ulcers. Which nursing intervention is most effective in preventing skin breakdown?
- AIncrease the intake of simple carbohydrates增加簡單碳水化合物的攝取
- BApply powder to all skin folds to maintain dryness在所有皮膚摺皺處塗抹粉劑以保持乾燥
- CMassage the bony prominences frequently經常按摩骨突處
- DReposition the client at least every two hours✓ 正解至少每兩小時重新安置患者姿勢
— Explanation · 中文詳解 —
預防壓力性損傷的核心原則是減輕持續性壓力。每兩小時翻身可以改善局部循環並釋放壓力。B 選項粉末容易結塊增加磨擦；C 選項按摩骨突處已證實會損傷皮下組織，現行指引已不建議；A 選項應補充蛋白質而非碳水化合物以促進傷口修復。
Repositioning the client at least every two hours is the most effective intervention for preventing pressure ulcers as it relieves sustained pressure on bony prominences. Other methods like massaging bony areas can cause tissue damage, while powders may increase friction, and simple carbohydrates do not support tissue integrity.
✦ 台美臨床差異
美國醫院廣泛使用 Braden Scale 進行評估，台灣醫療環境中護理師亦常用此量表，但臨床人力比差異會影響翻身頻率落實度。