— 基本照護與舒適 · MEDIUM · MCQ —
護理師在為持續鼻胃管灌食的病人進行晨間護理時，應優先採取哪項行動？
Which action should the nurse prioritize when providing morning care for a client with a continuous tube feeding?
- AAssess for placement and bowel sounds評估管路位置與腸鳴音
- BElevate the head of the bed to at least 30-45 degrees✓ 正解將床頭抬高至少30-45度
- CCheck gastric residual volume檢查胃殘留量
- DFlush the tube with 30 mL of water以30 mL水沖洗管路
— Explanation · 中文詳解 —
針對持續灌食病人，預防吸入性肺炎是最高原則，維持床頭抬高 30-45 度是維持呼吸道安全最有效的措施。雖然評估胃容積與腸蠕動很重要，但在執行常規護理前，確保病人姿勢正確是絕對優先事項，能有效降低反流風險。
When caring for a client with continuous tube feeding, the priority is preventing aspiration pneumonia by elevating the head of the bed to at least 30-45 degrees. This positioning utilizes gravity to reduce gastric reflux and maintain airway safety. While assessing placement and residuals is important, proper positioning is the primary intervention to mitigate aspiration risks during ongoing feedings.
✦ 台美臨床差異
美國非常強調管餵病人的長期姿勢管理；台灣臨床常因病人抱怨不適而將床頭放平，需加強對吸入風險的再教育。