# 將每項出院計畫發現拖曳至最能弭平照護轉銜缺口的行動領域。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393516&lang=zh-tw  
> language: zh-TW  
> subject: Continuity of Care  
> category: MOC

## 題目

將每項出院計畫發現拖曳至最能弭平照護轉銜缺口的行動領域。

**1.** 處方之居家氧氣尚未送達，且無備用計畫

Select a category
Resolve barrier before departure
Teach and verify understanding now
Create a closed-loop handoff or follow-up

**2.** 唯一的照顧者尚無法安全執行所需的雙人轉位

Select a category
Resolve barrier before departure
Teach and verify understanding now
Create a closed-loop handoff or follow-up

**3.** 個案無法說明哪些居家用藥已停用、變更或新開始使用

Select a category
Resolve barrier before departure
Teach and verify understanding now
Create a closed-loop handoff or follow-up

**4.** 照顧者無法示範傷口護理或說出需要致電的紅腫、引流液或發燒等徵象

Select a category
Resolve barrier before departure
Teach and verify understanding now
Create a closed-loop handoff or follow-up

**5.** 切片檢查結果將於出院後返回，但未記錄負責臨床人員或聯絡日期

Select a category
Resolve barrier before departure
Teach and verify understanding now
Create a closed-loop handoff or follow-up

**6.** 建議心臟科追蹤，但預約和轉介摘要尚未確認

Select a category
Resolve barrier before departure
Teach and verify understanding now
Create a closed-loop handoff or follow-up

## 解析

未解決的設備或照顧者能力障礙必須在出院前處理。用藥、傷口護理及警訊徵象衛教需要使用回示法確認，而非僅簽名。待完成的檢查和約診需要明確的負責人、日期、聯絡方式和交班，以免責任在轉銜過程中遺漏。

## 深入解析

快速解答
解決實務障礙、確認自我照護理解，並為結果和追蹤指派明確負責人。

為何此為正確
AHRQ的IDEAL框架納入個案與家屬，審查用藥、警訊徵象、檢驗結果和約診，並使用淺顯語言搭配回示法。出院是一個過程，而非最後一刻才準備的資料袋。

NCLEX決策規則
安全的轉銜回答三個問題：計畫能否在家中執行？個案或照顧者能否說明該做什麼？每個未解決的結果或追蹤任務由誰負責？參考資料
1AHRQ IDEAL Discharge Planning
2NCSBN 2026 NCLEX-RN Test Plan

## 臨床情境

醫院至居家轉銜
一位患有心衰竭且新出現腿部傷口的老年人預計今天下午出院。護理師運用個案與家屬夥伴關係、淺顯語言、回示法及明確的追蹤負責人。

## 重要概念

- **回示法** — 一種確認方法，由個案或照顧者以自己的話說明或示範計畫內容。
- **照護轉銜** — 臨床人員或照護機構之間的轉換，伴隨資訊、責任和追蹤的轉移。
- **用藥整合** — 對藥物清單進行結構化比較，以識別並解決遺漏、重複、劑量錯誤及非預期的差異。

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