一位使用鼻胃管餵食的病人，護理師在給予灌食前，最優先的評估項目為何？
A nurse is caring for a client with a nasogastric tube (NGT) for enteral feeding. What is the priority assessment before administering a bolus feeding?
- ACheck gastric residual volume檢查胃殘留量
- BVerify tube placement by auscultating air透過空氣聽診法確認管路位置
- CCheck the pH level of the gastric aspirate✓ 正解檢查胃吸出液的pH值
- DAssess bowel sounds評估腸蠕動音
根據最新護理實證指引，驗證鼻胃管正確位置的黃金標準是 pH 值檢測（pH < 5 為胃部位置）。B（聽診空氣）已被證明缺乏準確性，不應作為主要驗證依據。D（殘留量）在現代護理中已不再建議在每次灌食前常規執行，除非有臨床徵象懷疑消化不良，因此 pH 檢測仍是確定管路安全的基礎。
According to current evidence-based nursing guidelines, the gold standard for verifying correct nasogastric tube placement is pH testing of the gastric aspirate (a pH < 5 indicates gastric placement). Option B (auscultation of insufflated air) has been shown to lack accuracy and should not be relied on as a primary verification method. Option A (gastric residual volume) is no longer routinely recommended before each bolus feeding in modern practice, unless clinical signs suggest impaired digestion. Therefore, pH testing remains the foundation for ensuring safe tube placement.
台灣醫院目前仍高度依賴聽診法與抽吸物外觀，pH 試紙的使用普及率在部分基層醫療單位較低。