護理師照顧一位剛進行氣切術的病人，下列哪項措施對於維持呼吸道暢通最重要？
A nurse is caring for a client with a newly placed tracheostomy. Which nursing action is essential to maintain a patent airway?
- AAssess the amount, consistency, and color of secretions✓ 正解評估分泌物的量、性質和顏色
- BSuction the airway every hour每小時進行氣道抽吸
- CRemove the inner cannula every 4 hours每 4 小時移除內套管
- DChange the tracheostomy dressing twice a day每天更換兩次氣切紗布
氣切（Tracheostomy）護理的核心目標是確保氣道維持通暢且無感染。抽痰應採取「依需抽吸（PRN suctioning）」而非定時抽吸，因過度抽吸會導致黏膜損傷、缺氧及增加分泌物產生。評估分泌物的量、顏色與稠度（Consistency）能提供呼吸道健康狀況的關鍵指標，例如變稠可能表示脫水或感染，這直接決定了後續是否需要抽吸或給予濕化治療，是臨床護理決策的基礎。
The core goal of tracheostomy care is to maintain a patent and infection-free airway. Suctioning should be performed PRN rather than on a fixed schedule, because excessive suctioning damages the mucosa, causes hypoxia, and stimulates more secretions. Assessing the amount, color, and consistency of secretions provides key indicators of airway health; for example, thickened secretions may indicate dehydration or infection, which directly determines the need for further suctioning or humidification and forms the basis of clinical nursing decision-making.
美國臨床非常強調 Evidence-based practice（實證護理），對於氣切護理，除非有臨床徵象（如呼吸音聽到痰音、血氧下降），否則絕對禁止常規定時抽吸。台灣臨床單位有時仍有較多定時抽吸的習慣，考生在 NCLEX 考試中必須堅持依需抽吸原則。