— 基本照護與舒適 · MEDIUM · MCQ —
病人要求協助口腔清潔。護理師應先進行哪項評估？
A patient asks for help with oral hygiene. What assessment should the nurse perform first?
- AAsk about toothpaste flavor詢問牙膏口味
- BCheck for gum disease檢查是否有牙齦疾病
- CAssess for gag reflex✓ 正解評估吞嚥反射
- DObserve if the patient has loose teeth觀察病人是否有鬆動牙齒
— Explanation · 中文詳解 —
口腔護理（Oral hygiene）看似常規，但在臨床上必須優先評估病人的吞嚥功能與氣道保護反射。若病人缺乏嘔吐反射（Gag reflex），在進行口腔清潔時，液體或異物極易進入呼吸道，導致吸入性肺炎（Aspiration pneumonia）。因此，在進行任何口腔照護前，確保呼吸道安全是最高優先級。
Oral hygiene appears routine, but clinically the patient's swallowing function and airway-protective reflexes must be assessed first. If the gag reflex is absent, fluids or foreign material may easily enter the airway during oral care, leading to aspiration pneumonia. Therefore, ensuring airway safety is the highest priority before initiating any oral care.