護理師在為一位意識不清的病人進行口腔護理時，下列哪些措施是正確的？（選所有適合的）
Which interventions are appropriate for a nurse to implement when providing oral care for an unconscious client? (Select all that apply.)
- APlace the client in a side-lying (lateral) position✓ 正解將客戶置於側臥（外展）姿勢
- BUse a thumb and forefinger to keep the client's mouth open使用拇指和食指保持客戶嘴巴張開
- CKeep a portable suction machine at the bedside during the procedure✓ 正解在操作期間於床邊備妥便攜式抽吸機
- DApply lemon-glycerin swabs to the oral mucosa every hour每小時將檸檬甘油棉棒塗抹於口腔黏膜
- EClean the teeth and tongue using a soft-bristled toothbrush or foam swabs✓ 正解使用軟毛牙刷或海綿棒清潔牙齒和舌頭
意識不清病人的口腔護理首要考量是「防止吸入」與「安全」。側臥位（Lateral position）利用重力讓液體流向口角而非氣管，是標準姿勢。同時，床邊必須備妥抽吸設備（Suction），以便隨時移除口腔內的積水或分泌物。清潔工具應選擇軟毛牙刷或海綿棒。選項 B 是絕對禁止的，因為昏迷病人可能有咬合反射，用手指撐口極易受傷，應使用專業開口器。選項 D 的檸檬甘油棉棒已不再推薦，因為檸檬酸會損害牙釉質，甘油則會吸收水分導致粘膜更乾燥。高品質的口護能預防呼吸器相關肺炎（VAP）並維持粘膜完整性。
For oral care of an unconscious client, the primary concerns are preventing aspiration and ensuring safety. The lateral (side-lying) position uses gravity to direct fluids toward the corner of the mouth rather than the trachea and is the standard position. In addition, portable suction equipment must be available at the bedside to remove pooled fluid or secretions at any time. Cleaning tools should be a soft-bristled toothbrush or foam swab. Option B is absolutely prohibited, because comatose clients may have a bite reflex and using fingers to keep the mouth open easily causes injury; a professional bite block should be used instead. Option D is no longer recommended; citric acid damages tooth enamel, and glycerin draws moisture out, leaving the mucosa drier. High-quality oral care helps prevent ventilator-associated pneumonia (VAP) and maintains mucosal integrity.
美國 NCLEX 考題對「防止吸入」極為敏感，側臥與抽吸是必選。台灣臨床上部分病房仍習慣使用檸檬甘油棉棒（因其方便且味道好），但為符合國際最新實證，應逐步轉向使用生理食鹽水或無酒精漱口水。