護理師準備經由鼻胃管進行灌食。護理師應首要採取哪項行動？
The nurse is preparing to administer a bolus enteral feeding via a nasogastric (NG) tube. Which action should the nurse take first?
- AWarm the formula to room temperature.將灌食液回溫至室溫
- BFlush the tube with 30 mL of water.以 30 mL 水沖洗管路
- CAssess for bowel sounds in all four quadrants.評估四個象限的腸音
- DVerify the position of the NG tube.✓ 正解確認鼻胃管的位置
腸道營養的首要安全原則是「確保管路位置正確」。NG tube 容易因為咳嗽、翻身或嘔吐而位移進入氣管。若在錯誤位置灌食，會直接導致吸入性肺炎甚至窒息。因此，在每次灌食前，護理師必須先確認管路深度、回抽胃內容物觀察顏色或測試 pH 值（黃金標準為 X 光，但實務中以回抽為主）。確認位置後，才進行後續的殘餘量評估與沖管。雖然評估腸音（C）與回溫灌食液（A）也很重要，但相較於吸入風險，確認管路位置才是生命安全的第一道防線。沖洗管路（B）則是在確認位置與灌食前後才進行的動作。
The foremost safety principle for enteral nutrition is 'ensuring correct tube placement.' An NG tube can easily migrate into the trachea due to coughing, repositioning, or vomiting. Feeding through a misplaced tube directly causes aspiration pneumonia and even asphyxiation. Therefore, before each feeding, the nurse must first confirm tube depth, aspirate gastric contents to check color, or test the pH (the gold standard is X-ray, but in practice aspiration is the primary method). After confirming placement, residual volume assessment and tube flushing follow. Although assessing bowel sounds (C) and warming the formula (A) are also important, compared with the risk of aspiration, verifying tube placement is the first line of defense for life safety. Flushing the tube (B) is performed only after placement verification and before/after the feeding.
美國 NCLEX 考試中，確認 pH 值（<5.5）是驗證位置的首選非放射學方法；台灣臨床上則普遍使用氣泡聽診法（Whoosh test），儘管在實證醫學中氣泡聽診法的準確性備受質疑，但在台灣仍是標準流程之一。