# 一位狀況穩定、可行走的個案在戶外化學物質外洩後抵達，衣物和皮膚上有液體汙染。護理師應先採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=497915&lang=zh-tw  
> language: zh-TW  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## 題目

一位狀況穩定、可行走的個案在戶外化學物質外洩後抵達，衣物和皮膚上有液體汙染。護理師應先採取哪項行動？

## 選項

1. 護送個案進入治療室並取得完整的暴露史
2. 在測量生命徵象前用乾淨的床單覆蓋衣物
3. 引導個案至除汙區域脫除衣物並清洗 **✔ 正確答案**
4. 在進入機構前將含酒精的清潔劑塗抹於暴露的皮膚

**正確答案: 3**

## 解析

狀況穩定的汙染個案應在進入治療區域前先進行除汙。脫除衣物並清洗暴露的皮膚可減少吸收，並防止化學物質擴散至工作人員、其他個案及機構。

## 深入解析

快速解答
將狀況穩定的個案送至指定的除汙區域，脫除汙染衣物並清洗暴露的皮膚。這可在常規治療室照護前限制持續暴露和二次汙染。

為什麼這是正確的
衣物和皮膚上的化學物質可能持續被吸收並帶入機構內。脫除衣物可去除大部分表面汙染，溫和清洗則進一步減少化學物質，同時保護工作人員和其他個案免於擴散。

簡單比喻或心智圖像
汙染的衣物就像一個正在漏液的容器被帶進醫院。移除並隔離它可在清理繼續前阻止洩漏痕跡；此比喻不適用於對狀況不穩定的個案延遲救命的呼吸道或復甦措施。

記憶掛鉤
穩定的化學暴露意味著阻止擴散：除汙區域、脫除衣物、溫和清洗，然後常規照護。

NCLEX 決策規則
對於有外部化學汙染且狀況穩定的個案，在將個案帶入清潔治療區前應先預防二次暴露。使用指定的除汙流程和適當的工作人員防護；狀況不穩定的個案需要同時進行救生照護和汙染控制。

為什麼其他選項是錯的
將汙染物直接帶入治療室會擴散危害。覆蓋衣物無法去除化學物質，且含酒精的產品可能不適合用於皮膚除汙，並可能增加某些物質的吸收。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]CDC: About Getting Clean After a Chemical EmergencyCenters for Disease Control and Prevention

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