— 基本照護與舒適 · MEDIUM · SATA —
護理師準備對一位無意識病人執行口腔護理。下列哪些措施是確保安全所必須的？（選所有適合的）
A nurse is preparing to provide oral hygiene to an unconscious client. Which actions are necessary to ensure safety? (Select all that apply.)
- APlace the client in a side-lying position✓ 正解將病人置於側臥姿勢
- BUse a soft-bristled toothbrush or foam swab✓ 正解使用軟毛牙刷或海綿棒
- CPour water into the mouth to rinse thoroughly將水倒入口中徹底漱口
- DUse a padded tongue blade to keep the mouth open✓ 正解使用襯墊壓舌板以保持口腔張開
- EApply a petroleum-based lubricant to the lips在嘴唇上塗抹凡士林基質潤滑劑
— Explanation · 中文詳解 —
無意識病人缺乏吞嚥反射，必須採側臥防止吸入性肺炎。使用軟毛刷或棉棒避免損傷牙齦；張口器（舌壓板）應有襯墊以防咬傷。絕對不可直接灌水沖洗，會導致誤吸。嘴唇應用水溶性潤滑劑而非油性（如凡士林），因油性物質若誤吸會導致脂質性肺炎。
For an unconscious client, placing them in a side-lying position prevents aspiration of secretions during oral care. A padded tongue blade should be used to keep the mouth open safely without causing trauma. Soft-bristled brushes or foam swabs protect delicate mucous membranes, while direct pouring of water is prohibited due to high aspiration risk. Lip lubricants should be water-soluble to avoid lipid pneumonia if aspirated.
✦ 台美臨床差異
美國臨床多使用專用口腔護理包，台灣常見以棉棒沾食鹽水執行，執行標準化程度在美國較高。