護理師為一位意識不清的病人執行口腔護理。防止吸入性肺炎最重要步驟為何？
A nurse is planning to perform oral care for an unconscious client. What is the most important step to prevent aspiration?
- APositioning the client on their side✓ 正解將病人置於側臥姿勢
- BPerforming the procedure while the client is supine在病人仰臥時執行操作
- CUsing only a dry toothbrush僅使用乾牙刷
- DUsing a large amount of water to rinse使用大量水漱口
對於意識不清（Unconscious）的病人，保護呼吸道安全是護理介入的首要任務。口腔護理時，病人的吞嚥反射與咳嗽反射可能減弱或消失，若採仰臥（Supine）姿勢，口腔清潔液、唾液或分泌物極易經由重力流入氣管，引發吸入性肺炎（Aspiration pneumonia）。將病人擺放為側臥（Side-lying）姿勢，可利用重力使液體流向口腔外側，達到引流效果，這是預防誤吸最關鍵的物理防護措施。
For an unconscious client, protecting the airway is the highest nursing priority. During oral care, the client's swallowing and cough reflexes may be diminished or absent; in a supine position, oral rinsing solution, saliva, or secretions can drain by gravity into the trachea, causing aspiration pneumonia. Positioning the client in a side-lying position uses gravity to drain fluids out of the mouth and is the most important physical safeguard against aspiration.