— 照護管理 · EASY · MCQ —
護理師督導照服員照顧管灌餵食病人。下列哪項觀察發現需要護理師立即介入？
A nurse is supervising an assistive personnel (AP) who is providing care to a client receiving enteral feedings. Which observation requires immediate intervention by the nurse?
- AThe AP checks the expiration date on the feeding formula助理護理人員檢查餵食公式的有效期
- BThe AP measures the gastric residual volume before the next feed助理護理人員在下一次餵食前測量胃殘餘量
- CThe AP places the client in a supine position during the feeding✓ 正解助理護理人員在餵食期間將病人置於仰臥位
- DThe AP washes their hands before touching the feeding pump助理護理人員在觸摸餵食幫浦前洗手
— Explanation · 中文詳解 —
腸道餵食（enteral feeding）最嚴重的併發症之一是吸入性肺炎（aspiration pneumonia）。為了預防胃內容物逆流至食道並進入呼吸道，在餵食期間及餵食後至少 30-60 分鐘內，必須將病人的床頭抬高 30-45 度。若將病人平臥（supine），會直接導致胃內容物逆流，造成吸入風險。
Supine positioning significantly increases the risk of aspiration during enteral feedings because it allows gastric contents to reflux into the esophagus and airway. To prevent aspiration pneumonia, the nurse must ensure the client’s head of bed is elevated 30 to 45 degrees during and after feeding.