— 照護管理 · MEDIUM · MCQ —
護理長觀察 LPN/LVN 照顧管灌病人，哪項行為需要護理長介入？
A charge nurse is observing an LPN/LVN care for a client with a continuous tube feeding. Which action by the LPN/LVN requires the charge nurse to intervene?
- AChecking the tube placement using pH of aspirate使用抽取液的pH值檢查管路位置
- BVerifying the feeding formula against the physician's order根據醫師醫囑核對餵食配方
- CFlushing the tube with 30 mL of sterile water after medication administration給藥後用30 mL無菌水沖洗管路
- DPositioning the head of the bed at 15 degrees✓ 正解將床頭抬高15度
— Explanation · 中文詳解 —
管灌病人預防吸入性肺炎的基本原則是維持床頭抬高至少 30-45 度。床頭僅抬高 15 度會增加胃食道逆流及吸入性肺炎的風險。其他選項皆符合正確護理常規，pH 值檢測放置位置、藥物後沖洗導管、確認醫囑均為安全執行步驟。
Positioning the head of the bed at only 15 degrees increases the risk of gastroesophageal reflux and aspiration pneumonia; the head of the bed should be elevated to at least 30 to 45 degrees during continuous tube feedings. The other actions, such as checking pH for placement, verifying orders, and flushing with sterile water, are standard safe practices.
✦ 台美臨床差異
台灣醫院多強調床頭抬高 30 度以上，護理師需隨時稽核以符合病人安全指標。