— 照護管理 · MEDIUM · MCQ —
護理長觀察新進護理師評估疑似感染傷口的病人，哪項行為需要介入？
A charge nurse is observing a newly licensed nurse perform an assessment on a client with a suspected infectious wound. Which action by the new nurse requires intervention?
- APlacing contaminated dressings into a biohazard bag將污染的敷料放入生物危害袋中
- BWearing a gown and gloves before entering the room進入房間前穿戴隔離衣和手套
- CPerforming hand hygiene before putting on gloves戴上手套前執行手部衛生
- DTouching the wound bed with a sterile swab before cleaning✓ 正解在清潔之前用無菌拭子觸碰傷口床
— Explanation · 中文詳解 —
傷口評估時，護理師應先觀察傷口周圍皮膚、評估滲液量與性質，再依需要進行採檢。在未經清潔與評估前直接以拭子（或任何物件）觸碰傷口床（D），會破壞無菌原則並可能將表皮菌帶入傷口深部，影響後續評估與培養品質，故為需要立即介入的行為。其他選項：C 戴手套前手部衛生為標準感控；B 於進房前穿戴隔離衣與手套符合接觸隔離；D 將污染敷料放入生物危害袋為標準廢棄物處理。
Touching the wound bed with a sterile swab before cleaning and assessing the surrounding skin breaches standard infection control protocols. This action risks introducing surface bacteria into the deeper wound tissue and contaminates the sample, potentially compromising the accuracy of wound cultures and assessment.