護理師檢查接受持續管灌餵食病人的胃殘餘量 (GRV)，發現殘餘量為 150 mL。護理師應採取哪項行動？
A nurse is checking the gastric residual volume (GRV) of a client receiving continuous enteral feedings. Which action should the nurse take if the residual is 150 mL?
- ADiscard the residual and notify the physician丟棄殘餘量並通知醫師
- BDiscard the residual and stop the feeding丟棄殘餘量並停止灌食
- CReturn the residual and continue the feeding✓ 正解回置殘餘量並繼續灌食
- DReturn the residual and hold the feeding for 1 hour回置殘餘量並暫停灌食 1 小時
根據最新指南（如 ASPEN），胃殘餘量低於 250-500 mL 通常不需停止灌食，應將殘餘量回置（預防電解質流失）並繼續灌食。150 mL 在安全範圍內。頻繁停止灌食會導致病人營養攝取不足，增加營養不良風險。若殘餘量超過 500 mL 或伴隨腹脹、嘔吐才需停止。
According to current guidelines (such as those from ASPEN), gastric residual volumes below 250-500 mL generally do not require interruption of feeding; the residual should be returned (to prevent electrolyte loss) and feeding continued. A volume of 150 mL is within the safe range. Frequent interruption of feedings leads to inadequate nutritional intake and increases the risk of malnutrition. Feeding should be held only if the residual volume exceeds 500 mL or if accompanied by abdominal distension or vomiting.
美國 ASPEN 指南已建議不再常規監測 GRV；台灣臨床目前仍多維持每 4-8 小時抽吸一次，標準多定在 50-100 mL 即考慮暫停。