護理師正在為一位意識不清的病人進行口腔護理。應採取哪些措施？（選所有適合的）
A nurse is performing oral care for an unconscious client. Which actions should the nurse take? (Select all that apply.)
- APlace the client in a side-lying (lateral) position.✓ 正解將病人置於側臥位（側躺）。
- BUse a padded tongue blade to keep the mouth open.✓ 正解使用有襯墊的壓舌板以保持嘴巴張開。
- CClean the teeth and gums using a small, soft toothbrush.✓ 正解使用小型軟毛牙刷清潔牙齒和牙齦。
- DUse the nurse's thumb and forefinger to hold the mouth open.使用護理師的大拇指和食指撐開嘴巴。
- EApply water-soluble lubricant to the client's lips.✓ 正解在水溶性潤滑劑塗抹於病人的嘴唇上。
意識不清病人的口腔護理重點是「預防吸入」與「安全操作」。採取側臥位（A）能讓分泌物順著重力流出口腔，防止流入氣管。使用墊棉壓舌板（B）能穩定支撐牙關，避免病人因反射性咬合受傷。軟毛牙刷（C）比海綿刷更能有效移除牙菌斑，預防 VAP（呼吸器相關肺炎）。潤滑嘴唇（E）預防龜裂。選項 D 是絕對禁忌，因為意識不清者可能有原始反射（咬合反射），護理師的手指若伸入極易被咬傷。整體目標是移除病原菌並維持黏膜完整性，同時確保呼吸道安全。
Oral care for an unconscious client centers on aspiration prevention and safe technique. Placing the client in a side-lying (lateral) position (A) allows secretions to drain out of the mouth by gravity, preventing entry into the trachea. A padded tongue blade (B) safely keeps the jaw open and prevents reflexive biting that could cause injury. A soft toothbrush (C) is more effective than a foam swab at removing dental plaque and helps prevent ventilator-associated pneumonia (VAP). Lubricating the lips (E) prevents cracking. Option D is absolutely contraindicated because an unconscious client may exhibit primitive reflexes (such as the bite reflex); inserting the nurse's fingers into the mouth poses a high risk of injury. The overall goals are pathogen removal and maintenance of mucosal integrity while protecting the airway.
美國 NCLEX 考題非常強調側臥位（Lateral position）預防吸入。台灣臨床有時僅使用海綿刷快速擦拭，但研究顯示牙刷清潔效果更佳，且美式衛教極力反對將手指放入病人嘴內。