— 安全與感染控制 · HARD · MCQ —
護理師向實習護生說明約束的使用，哪項敘述代表護生已理解？
A nurse is teaching a student nurse about restraint usage. Which statement by the student indicates understanding?
- ANeurovascular assessment should be performed every 2 hours應每 2 小時進行神經血管評估。
- BA physician's order for restraints can be PRN約束的醫師醫囑可以是 PRN（按需）。
- CRestraints must be released periodically for skin care and range of motion✓ 正解必須定期解開約束以進行皮膚護理和關節活動度訓練。
- DRestraints should be tied to the side rail for easy access約束應綁在床欄上以便於存取。
— Explanation · 中文詳解 —
約束為最後手段。約束帶應綁在病床架（Bed frame）而非側欄，以防側欄升降造成傷害。醫師醫囑不得開立 PRN（必要時）約束，必須是具時效性的。神經血管評估通常要求每小時執行，且需定時鬆開進行活動與皮膚護理。
Restraints must be periodically released to allow for skin care, range-of-motion exercises, and circulation checks to prevent complications like pressure ulcers. They should be secured to the bed frame rather than side rails to avoid injury if the rail is lowered. Additionally, neurovascular assessments are typically required hourly, and restraints require a time-limited physician order, not a PRN order.
✦ 台美臨床差異
美國對約束的法律規範極為嚴謹，紀錄要求繁瑣；台灣亦有規範，但臨床依賴性略高。