— 照護管理 · MEDIUM · MCQ —
護理長觀察新進護理師照護鼻胃管病人，哪種行為顯示需要進一步指導？
A charge nurse is observing a newly hired nurse care for a client with a nasogastric (NG) tube. Which action by the new nurse indicates a need for further teaching?
- AFlushing the tube with 30 mL of water before and after medication administration給藥前後以 30 mL 水沖洗管路
- BVerifying the tube marking at the nostril to ensure it has not migrated確認鼻孔處的管路標記，以確保管路未發生位移
- CPositioning the client with the head of the bed flat while administering a bolus feeding✓ 正解灌食時將病人床頭放平
- DChecking tube placement by measuring the pH of aspirated gastric contents通過測量抽吸出的胃內容物 pH 值來確認管路位置
— Explanation · 中文詳解 —
鼻胃管（NG tube）灌食時，預防吸入性肺炎（Aspiration pneumonia）是護理安全的核心。為了利用重力協助食物進入胃部並防止胃內容物反流，病人必須採取半坐臥姿（Semi-Fowler's position），通常床頭需抬高 30 至 45 度。將床頭放平會大幅增加誤吸風險，尤其對於意識不清或管灌病人，此行為必須立即糾正。
Aspiration pneumonia prevention is central to NG tube feeding safety. To use gravity to direct food into the stomach and prevent reflux, the client must be in semi-Fowler's position with the head of bed elevated 30-45 degrees. Flat positioning during feeding significantly increases aspiration risk, especially in unconscious or tube-fed clients, and must be corrected immediately.