護理師正在照顧一位接受持續性鼻胃管灌食的病人。下列哪項護理措施對預防併發症最重要？
A nurse is managing the care of a client with a continuous NG tube feeding. Which nursing action is most important to prevent complications?
- AFlush the tube with 100 mL of water after medications.給藥後以 100 mL 水沖洗管路
- BWarm the feeding formula to body temperature in a microwave.用微波爐將灌食配方加熱至體溫
- CCheck gastric residual volume every 24 hours.每 24 小時檢查胃殘留量
- DKeep the head of the bed elevated 30 to 45 degrees.✓ 正解保持床頭抬高 30 至 45 度
持續性灌食最大的風險是逆流導致吸入性肺炎。維持床頭抬高 30-45 度（D）是預防此類嚴重併發症的最關鍵措施，能利用重力減少胃內容物進入食道。選項 C（每 24 小時檢查殘餘量）頻率太低，通常應每 4-6 小時檢查一次。選項 A（沖洗 100 mL）過量，一般藥後沖洗 15-30 mL 即可，過多水分會造成液體負荷。選項 B（微波加熱）絕對禁止，因為會造成溫度不均引發燙傷，灌食液通常維持室溫即可。護理優先原則是「安全與氣道保護」，床頭高度是首要防線。
The greatest risk of continuous feeding is reflux leading to aspiration pneumonia. Maintaining the head of the bed elevated 30-45 degrees (D) is the most critical measure for preventing this serious complication, as it uses gravity to reduce gastric content reflux into the esophagus. Option C (checking residuals every 24 hours) is too infrequent; checks should generally be performed every 4-6 hours. Option A (flushing with 100 mL) is excessive; 15-30 mL after medications is generally sufficient, as excess water can cause fluid overload. Option B (microwave heating) is strictly forbidden, as uneven heating can cause burns; feeding formula should generally be kept at room temperature. The nursing priority is 'safety and airway protection,' and head-of-bed elevation is the first line of defense.
美國 NCLEX 與最近趨勢（ASPEN 指南）對於是否例行檢查殘餘量（GRV）有爭議，但床頭抬高永遠是正確答案。台灣臨床仍嚴格要求每班檢查殘餘量（通常 >50-100cc 需暫緩），護理師應靈活運用。