# 在進行無菌換藥時，護理師注意到一塊無菌紗布掉落到腰部以下。護理師該怎麼做？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397270&lang=zh-tw  
> language: zh-TW  
> subject: Incident Reporting  
> category: SIPC

## 題目

在進行無菌換藥時，護理師注意到一塊無菌紗布掉落到腰部以下。護理師該怎麼做？

## 選項

1. 丟棄該紗布，因為它已被汙染。 **✔ 正確答案**
2. 如果紗布沒有碰到地板，就繼續使用。
3. 將紗布放回無菌區域。
4. 用無菌生理食鹽水沾濕紗布以恢復無菌狀態。

**正確答案: 1**

## 解析

腰部以下的物品被視為已汙染，因為它們超出了護理師的視線範圍和無菌控制區。無菌狀態無法透過沾濕物品來恢復。被汙染的紗布應丟棄。

## 深入解析

臨床判斷
運用個案線索、時機、檢驗數據及安全風險，選出最符合「無菌區域汙染」情境的回應。

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，而非單獨的回憶。

## 臨床情境

臨床實務指引
針對「無菌區域汙染」，將完整的線索模式與個案當前的穩定性、醫囑數據及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，切勿僅根據單一線索選擇行動。

## 重要概念

- **無菌區域** — 為進行醫療處置而準備的、保持無微生物的區域。
- **外科無菌操作** — 維持無菌狀態並防止汙染的實務操作。
- **汙染** — 因接觸或不安全的放置位置而導致無菌狀態喪失。

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