還有更多這樣的題目挑戰 ›

護理師為一位活動受限的個案更新壓力損傷預防計畫。針對每個線索或行動，選擇最佳分類。

Matrix

選擇作答後，查看答案。

	Risk factor requiring plan adjustment需要調整計畫的風險因子	Evidence-based prevention action實證預防行動	Early tissue injury requiring reassessment需要重新評估的早期組織損傷
Frequent urinary leakage leaves the sacral skin repeatedly moist despite cleansing頻繁的尿液滲漏使得薦骨處皮膚儘管已清潔仍反覆處於潮濕狀態
Reduced heel perfusion is accompanied by poor intake and inability to shift weight independently足跟灌注減少伴隨進食量少且無法獨立轉移重量
Set an individualized turning schedule based on mobility, skin tolerance, comfort, and the support surface根據活動力、皮膚耐受度、舒適度及支撐面設定個人化的翻身時間表
Inspect visible pressure points during each turn and float the heels while maintaining alignment在每次翻身時檢查可見的壓力點，並在維持身體排列的同時懸空足跟
A persistent darker area over the sacrum feels warmer and firmer than surrounding tissue after offloading薦骨處一個持續較暗的區域在減壓後摸起來比周圍組織更溫暖且更堅實
The intact heel is newly painful and boggy compared with the opposite heel完整的足跟與對側足跟相比，出現新的疼痛且呈水腫鬆軟狀

查看答案

相同主題的下一題A nurse is caring for a 75-year-old client with limited mobility and urinary incontinence …本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。