— 基本照護與舒適 · HARD · MCQ —
護理師協助一位吞嚥困難的病人進食。哪項措施優先預防吸入性肺炎？
A nurse is preparing to feed a client with dysphagia. Which intervention should the nurse prioritize to prevent aspiration?
- AInstruct the client to tilt their head back指示病人將頭部向後傾
- BOffer thin liquids to ease swallowing提供稀薄液體以減輕吞嚥困難
- CFeed the client as quickly as possible盡快餵食病人
- DPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
— Explanation · 中文詳解 —
吞嚥困難病人的首要安全是維持垂直姿勢（high-Fowler's，至少 90 度），利用重力幫助吞嚥。薄液體（B）最易吸入，需使用增稠劑。後仰頭（A）會打開氣管入口，應採取頸部前屈（chin tuck）。
Placing the client in a high-Fowler's position utilizes gravity to facilitate safe swallowing and significantly reduces the risk of aspiration. This upright posture is prioritized over other interventions, as tilting the head back or offering thin liquids increases aspiration risk.
✦ 台美臨床差異
美國臨床多有語言治療師（SLP）介入評估吞嚥測試，台灣護理師常需根據經驗自行判斷稠度。