— 基本照護與舒適 · MEDIUM · MCQ —
護理師為意識不清的病人執行口腔護理。下列哪項預防措施最重要？
A nurse is preparing to provide oral hygiene to an unconscious client. What is the most important precaution?
- AApply lubricant to the lips afterward事後塗抹潤唇膏
- BPosition the client on their side✓ 正解將病人置於側臥姿勢
- CKeep the mouth closed during the procedure操作期間保持嘴巴閉合
- DUse a lemon-glycerin swab使用檸檬甘油棉棒
— Explanation · 中文詳解 —
意識不清的病人吞嚥反射減弱或消失，口腔護理時最需預防液體誤入呼吸道導致吸入性肺炎。將病人採側臥位（側向護理師），可使液體自然流出，避免積聚在咽喉部。其他選項如潤唇（A）重要但非首要安全考量，檸檬甘油（D）會使黏膜乾燥應避免。
Unconscious clients have diminished or absent swallowing reflexes, so the greatest precaution during oral care is preventing fluid from entering the airway and causing aspiration pneumonia. Positioning the client on the side (facing the nurse) allows fluids to drain naturally and prevents pooling in the pharynx. Other options such as lip lubrication (A) are important but not the primary safety consideration, and lemon-glycerin (D) causes mucosal dryness and should be avoided.
✦ 台美臨床差異
台灣臨床護理常使用海綿刷，美國強調使用牙刷效果更好，但針對無意識病人都極度重視側臥位預防吸入。