護理師照護一位正在進行連續管灌飲食的病人，哪項評估發現需要立即暫停灌食？
A nurse is caring for a client with a continuous tube feeding. Which assessment finding requires the nurse to pause the infusion immediately?
- AThe feeding tube appears slightly pulled back餵食管似乎稍微退出
- BThe client reports mild abdominal bloating個案報告輕微腹部脹氣
- CThe residual volume is 50 mL殘餘量為 50 mL
- DThe client is lying flat in bed✓ 正解個案平躺在病床上
管灌飲食（Tube feeding）期間，預防吸入性肺炎（Aspiration pneumonia）是護理安全的核心。平躺位會顯著增加胃食道逆流的風險，若內容物逆流至咽喉並誤吸入氣管，將導致嚴重的呼吸道併發症。根據臨床護理規範，接受管灌飲食的病人，床頭必須抬高至少 30 至 45 度，以利用重力維持內容物在胃部，並減少逆流發生的機率。當病人處於平躺狀態時，發生誤吸的風險極高，因此必須立即暫停灌食，調整床位後再恢復。
During tube feeding, preventing aspiration pneumonia is the core of nursing safety. A supine position significantly increases the risk of gastroesophageal reflux; if contents reflux to the pharynx and are aspirated into the trachea, severe respiratory complications can occur. According to clinical nursing standards, patients receiving tube feeding must have the head of the bed elevated at least 30 to 45 degrees to use gravity to keep contents in the stomach and reduce the probability of reflux. When the patient is supine, the risk of aspiration is extremely high, so feeding must be paused immediately, and feeding resumed only after the bed position is adjusted.
美國臨床護理實務中，對於管灌殘餘量的評估標準已趨向減少頻繁抽吸，許多機構已不再將 50-100 mL 作為強制暫停的標準，除非有明顯腹脹或噁心。台灣臨床則較常執行常規殘餘量檢查。