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發現一位使用抗凝血劑的老年個案在無人目擊跌倒後倒臥於地，請將護理措施依序排列。

Ordered Response

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Remain with the client, stop unassisted movement, call for help, and address any immediate environmental danger 留在個案身旁，阻止個案在無人協助下移動，呼叫求援，並處理任何立即的環境危險

Notify the responsible clinician or emergency team promptly and prepare for indicated imaging, treatment, and enhanced observation 立即通知負責的臨床醫師或緊急團隊，並準備進行必要的影像檢查、治療及加強觀察

Assess responsiveness, airway, breathing, circulation, cervical-spine risk, and obvious bleeding before moving the client 在移動個案前評估意識反應、呼吸道、呼吸、循環、頸椎風險及明顯出血

Document the objective findings and response, complete required reporting, and revise the individualized fall-prevention plan 記錄客觀發現與處置反應，完成必要的通報，並修訂個別化跌倒預防計畫

Obtain baseline vital signs, neurologic status and Glasgow Coma Scale, glucose when indicated, pain, injuries, and the medication history 取得基準生命徵象、神經學狀態及格拉斯哥昏迷指數、必要時的血糖、疼痛、損傷及用藥史

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相同主題的下一題A circulating nurse leads the final time-out for an operative procedure. Complete the safe…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。