護理師為昏迷病人執行口腔護理。哪項措施是確保安全的首要任務？
The nurse is providing oral care to an unconscious client. Which action is the priority to ensure safety?
- AUse a large amount of water to rinse the mouth.使用大量清水漱口。
- BPosition the client in a side-lying (Sims) position.✓ 正解將病人置於側臥（Sims）體位。
- CKeep the client in a supine position with the head of the bed flat.讓病人保持仰臥位且床頭放平。
- DClean the tongue with a dry gauze pad.用乾燥紗布墊清潔舌頭。
對於昏迷病人，口腔護理最大的風險是誤吸（Aspiration）。將病人置於側臥位（Sims position）或側頭位，可以讓唾液或清潔液順著重力流出口腔，預防進入氣管。絕對不可平臥（C），這會增加窒息風險。清洗時應使用吸水球或小棉棒，避免大量清水灌洗（A）。乾燥紗布（D）可能會損傷黏膜且清潔效果有限。
For an unconscious client, the greatest risk during oral care is aspiration. Placing the client in a side-lying (Sims) position or with the head turned to the side allows saliva and cleaning solution to drain out of the mouth by gravity, preventing entry into the trachea. The client must never be kept supine (option C), as this increases the risk of asphyxiation. Cleaning should be performed with a bulb syringe or small swabs, avoiding rinsing with large amounts of water (option A). Dry gauze (option D) can injure the mucosa and provides limited cleaning effect.
美國 NCLEX 強調必須備妥 Suction（抽吸設備）在床邊；台灣教學亦然，但在實際執行中對側臥位的強調極高。