# 一位臥床不起的個案在薦骨處出現無法變白的紅斑。哪項護理措施最為適當？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396625&lang=zh-tw  
> language: zh-TW  
> subject: Mobility/Immobility  
> category: BCC

## 題目

一位臥床不起的個案在薦骨處出現無法變白的紅斑。哪項護理措施最為適當？

## 選項

1. 每班用力按摩發紅區域。
2. 將個案直接置於發紅區域上，以減少其他部位的壓力。
3. 在薦骨處使用熱敷以增加循環。
4. 為個案翻身並解除薦骨處的壓力。 **✔ 正確答案**

**正確答案: 4**

## 解析

無法變白的紅斑暗示早期壓力性損傷，必須解除壓力。按摩和熱敷可能損傷脆弱的組織。翻身和解除壓力是保護皮膚完整性的關鍵護理措施。

## 深入解析

臨床判斷
利用個案線索、時間點、檢驗數據和安全風險，選擇最符合壓力性損傷預防的反應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實踐指引
對於壓力性損傷預防，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **Pressure Injury** — 由壓力或壓力合併剪力造成的局部皮膚或組織損傷。
- **Nonblanchable Redness** — 按壓時不會變白的紅斑，可能表示組織損傷。
- **Offloading** — 減少身體脆弱部位的壓力。

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_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_