對於接受連續鼻胃管灌食的病人，哪項護理評估最重要？
Which assessment is most important to perform on a client receiving continuous tube feeding?
- AMonitoring skin integrity of the insertion site監測插入部位的皮膚完整性
- BAssessing for abdominal distention✓ 正解評估腹部膨脹
- CMeasuring the client's urine output hourly每小時測量病人的尿液排出量
- DChecking the residual volume every 4-6 hours每4-6小時檢查殘留量
在連續鼻胃管灌食中，最重要的安全評估其實是「確認鼻胃管位置」（pH、X 光標記等），可預防誤吸與灌入呼吸道。本題提供的四個選項中沒有此項，因此在現有選項裡，B「評估腹部膨脹」最為關鍵：腹脹是灌食不耐受、胃排空遲緩或腸阻塞的早期警訊，可能引發嘔吐與誤吸性肺炎。A 檢查餘量在現行實證中已較不被強調；B 尿量為一般生命徵象；D 為例行皮膚照護，安全優先性較低。
During continuous nasogastric tube feeding, the most important safety assessment is actually 'confirming nasogastric tube placement' (pH, X-ray marker, etc.), which prevents aspiration and infusion into the airway. None of the four options provided include this; therefore, among the current options, B ('assessing for abdominal distension') is the most critical: abdominal distension is an early warning sign of feeding intolerance, delayed gastric emptying, or intestinal obstruction, and may cause vomiting and aspiration pneumonia. Checking residuals (D) is now less emphasized in current evidence; urine output (C) is a general vital sign; A is routine skin care, with lower safety priority.
美國部分醫院已減少常規抽測餘量（Residual），台灣仍普遍將其列為 SOP。