# 一位臥床不動的個案，薦骨處出現按壓不變白的紅斑。護理師應執行哪項措施？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397179&lang=zh-tw  
> language: zh-TW  
> subject: Mobility/Immobility  
> category: BCC

## 題目

一位臥床不動的個案，薦骨處出現按壓不變白的紅斑。護理師應執行哪項措施？

## 選項

1. 每班用力按摩發紅區域。
2. 為個案翻身，解除薦骨處的壓力。 **✔ 正確答案**
3. 持續將床頭搖高至90度。
4. 直接在發紅區域使用熱敷。

**正確答案: 2**

## 解析

按壓不變白的紅斑表示早期壓力性損傷，必須解除壓力。按摩和熱敷可能損傷組織。持續將床頭搖高會增加薦骨處的剪切力和壓力。

## 深入解析

臨床判斷
使用個案線索、時機、檢驗數據和安全風險，選擇最適合薦骨壓力性損傷預防的回應。

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，而非孤立記憶。

## 臨床情境

臨床實務指引
對於薦骨壓力性損傷預防，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順序或安全性時，不要僅根據一個孤立的線索選擇行動。

## 重要概念

- **壓力性損傷** — 因壓力或剪切力導致的局部皮膚或皮下組織損傷。
- **按壓不變白的紅斑** — 按壓時不會變白的紅斑，暗示組織損傷。
- **翻身擺位** — 改變身體姿勢以減輕壓力並增進舒適。

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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。_