— 基本照護與舒適 · MEDIUM · MCQ —
護理師為意識不清的病人進行口腔護理，哪項措施能預防吸入性肺炎？
A nurse is providing hygiene care for an unconscious client. Which action is essential to prevent aspiration?
- APlace the client in a side-lying position✓ 正解將病人置於側臥姿勢
- BUse a soft toothbrush dipped in mouthwash使用沾有漱口水軟毛牙刷
- CUse a tongue depressor to keep the mouth open使用壓舌板保持嘴巴張開
- DClean the mouth every 8 hours每 8 小時清潔口腔一次
— Explanation · 中文詳解 —
意識不清的病人吞嚥反射減弱，口腔護理時最危險的是水分流入口腔深處導致吸入。側臥可利用重力讓液體流出，避免嗆入氣管。A 若含過多水分仍有危險；C 是頻率非防護措施；C 雖能撐開嘴巴，但無法防止液體嗆入。
Unconscious clients have a diminished swallowing reflex, and the greatest risk during oral care is that fluid flows deep into the oral cavity and is aspirated. The lateral position uses gravity to allow fluids to drain outward, preventing aspiration into the trachea. Option B still poses a risk if excessive water is used; C concerns frequency rather than a protective measure; and C, although it can keep the mouth open, cannot prevent aspiration of fluids.
✦ 台美臨床差異
台美臨床對於口腔護理執行頻率相似，但在使用抽吸設備時，美國護理師更傾向使用 YANKAUER 抽吸管即時引流。