護理師正準備為一位意識不清的病人進行口腔護理。為了確保病人安全，哪項措施是首要考量？
A nurse is preparing to perform oral care for an unconscious client. Which action is the priority for client safety?
- AApplying a small amount of petroleum jelly to the lips在嘴唇上塗抹少量凡士林
- BPositioning the client in a side-lying (lateral) position with the head turned toward the nurse✓ 正解將病人置於側臥（側躺）位，頭轉向護理師
- CCleansing the oral cavity with lemon-glycerin swabs使用甘油檸檬棉棒清潔口腔
- DUsing a soft-bristled toothbrush to clean the teeth使用軟毛牙刷清潔牙齒
對於意識不清的病人，口腔護理的核心概念是預防吸入性肺炎。由於這些病人通常失去咳嗽與吞嚥反射，液體極易進入氣管造成窒息或肺部感染。將病人置於側臥位並使頭部偏向一側，是利用重力原理讓口腔內的液體自然流出。雖然刷牙、潤唇是護理內容，但與生命安全（呼吸道保護）相比，姿勢擺位永遠是第一優先。吸入性肺炎是長期臥床病人常見的死因，因此在進行任何涉及液體的口腔處置前，必須先確保排除液體的路徑。臨床上應隨時備好抽吸設備，以應對突發狀況。護理師必須理解，基本的清潔動作若不配合正確的體位，會從『照護』變成『傷害』。
For an unconscious client, the core concept of oral care is the prevention of aspiration pneumonia. Because such clients typically lose their cough and swallowing reflexes, fluid can easily enter the trachea, causing asphyxia or pulmonary infection. Placing the client in a lateral position with the head turned to one side uses gravity to allow oral fluids to drain naturally. Although brushing teeth and moisturizing the lips are part of oral care, when compared with life safety (airway protection), positioning is always the first priority. Aspiration pneumonia is a common cause of death in long-term bedridden clients, so a clear drainage pathway must be ensured before any oral procedure involving fluids. Suction equipment should always be readily available in case of emergencies. The nurse must understand that without correct positioning, basic hygiene actions can shift from "care" to "harm."
在美國，口腔護理常包含在 VAP（呼吸器相關肺炎）預防組合中，強調使用 0.12% Chlorhexidine；台灣臨床則常使用生理食鹽水或含漱液配合海綿棒，側臥位在兩地皆為標準程序。