— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位留置鼻胃管的病人。投藥前應執行什麼動作？
A nurse is caring for a client with a nasogastric tube. What should the nurse do before administering medication?
- ACheck the pH of the gastric aspirate✓ 正解檢查胃抽吸液的 pH 值
- BConfirm placement via chest X-ray every time每次均透過胸部 X 光確認管路位置
- CInject air to listen for a swishing sound注入空氣並聽診是否有嘶嘶聲
- DAlways flush with at least 100 mL of water始終至少以 100 mL 水沖洗管路
— Explanation · 中文詳解 —
確認管路位置的黃金標準是 X 光，但每次投藥前無法拍 X 光。pH 值檢測（<5.5）是臨床常見的確認輔助。聽氣泡聲（C）準確度低且易造成誤判。沖水量建議 30-50mL，100mL 太多會造成病人胃脹。
The gold standard for confirming tube placement is X-ray, but an X-ray cannot be obtained before every medication administration. pH testing (<5.5) is a commonly used adjunctive bedside confirmation. The air bubble auscultation method (C) has low accuracy and can easily lead to misjudgment. The recommended flush volume is 30-50 mL; 100 mL is excessive and will cause gastric distension.
✦ 台美臨床差異
兩地皆逐漸淘汰聽氣泡法，轉向 pH 值確認與管路刻度追蹤。