— 基本照護與舒適 · MEDIUM · MCQ —
護理師為一位意識不清的病人進行口腔護理，防止吸入性肺炎最重要的是？
A nurse is providing hygiene care for an unconscious client. What is the most important consideration to prevent aspiration?
- APerform the procedure every 4 hours每 4 小時執行一次
- BUse a small amount of toothpaste使用少量牙膏
- CPosition the client's head to the side✓ 正解將病人頭部轉向側邊
- DUse a soft-bristled toothbrush to clean teeth使用軟毛牙刷清潔牙齒
— Explanation · 中文詳解 —
對於意識不清（Unconscious）的病人，保護呼吸道（Airway）是護理的首要優先（ABC原則）。口腔護理時，因病人缺乏吞嚥反射，液體容易蓄積在口腔後部。將頭側向一邊（Side-lying/Lateral position）利用重力引流，可有效防止液體流入氣管造成吸入性肺炎（Aspiration pneumonia）。
For an unconscious client, maintaining a patent airway is the highest priority according to ABC principles. Positioning the head to the side utilizes gravity to allow secretions to drain from the mouth, effectively preventing aspiration into the lungs.