— 基本照護與舒適 · HARD · MCQ —
護理師準備餵食一位有吞嚥困難的病人。下列哪項預防吸入性肺炎的措施優先級最高？
A nurse is preparing to feed a client who has dysphagia. Which intervention is the highest priority for preventing aspiration?
- AEnsure the client is in a high-Fowler’s position✓ 正解確保客戶處於高福勒氏體位（High-Fowler's position）
- BOffer small, frequent bites of food提供少量且頻繁的食物
- CThicken all liquids to nectar consistency將所有液體增稠至蜜糖狀濃度
- DAssess the client's gag reflex before every meal在每餐前評估客戶的嘔吐反射
— Explanation · 中文詳解 —
高坐姿（High-Fowler's）利用重力協助食團下降，並閉鎖氣管保護機制，是預防吸入的首要物理屏障。調整飲食質地與分量是輔助手段，而反覆測量嘔吐反射（gag reflex）在臨床上並不具備隨時執行且能精準預防吸入的實證效力，且過度刺激易誘發嘔吐。
Positioning the client in a high-Fowler’s position is the highest priority intervention to prevent aspiration during feeding. This upright posture uses gravity to facilitate safe swallowing and helps protect the airway. While other measures like thickening liquids are important, proper positioning is the fundamental first step in ensuring safe oral intake.
✦ 台美臨床差異
美方常有語言治療師（SLP）介入指導吞嚥菜單；台灣多由護理師觀察後與醫師溝通，對飲食質地的調整較為彈性。