出現下列哪種狀況，護理師應暫停管灌餵食？
Which of the following conditions would indicate the nurse should pause enteral tube feedings?
- AGastric residual volume is excessively high✓ 正解胃殘留量過高
- BThe client is sitting upright病人採坐直姿勢
- CBowel sounds are present存在腸鳴音
- DThe tube is correctly placed管路位置正確
管灌餵食（Enteral nutrition）的安全性評估關鍵在於預防誤吸（Aspiration）。胃餘容積（Gastric residual volume, GRV）過高通常代表胃部排空延遲，若強行繼續灌食，過多的液體積聚會導致腹脹、噁心，甚至引發胃食道逆流，進而增加吸入性肺炎的風險。臨床上，護理師應定期監測 GRV，若數值高於機構設定標準（通常為 250-500 mL），則需暫停餵食並回報醫師評估。
The key safety assessment in enteral nutrition is prevention of aspiration. An excessively high gastric residual volume (GRV) typically indicates delayed gastric emptying. Continuing the feeding despite this can cause abdominal distention, nausea, and gastroesophageal reflux, thereby increasing the risk of aspiration pneumonia. Clinically, the nurse should monitor GRV at regular intervals; if the value exceeds the institutional threshold (commonly 250-500 mL), the feeding should be held and the physician notified for further evaluation.
美國醫院對於 GRV 的監測政策差異很大，許多實證醫學指引（如 ASPEN）建議若無明顯症狀，可不必頻繁監測 GRV，但在 NCLEX 考試中，仍視高 GRV 為需採取行動的警訊。