— 照護管理 · MEDIUM · MCQ —
護理師監督助理人員（AP）為吞嚥困難病人進行口腔護理。助理人員哪個行為需立即介入？
A nurse is supervising an assistive personnel (AP) who is performing oral care for a client with a history of dysphagia. Which action by the AP requires immediate intervention?
- AUsing a large amount of water for oral rinsing✓ 正解使用大量水進行口腔漱口
- BPositioning the client in a high Fowler's position將病人置於高福勒氏體位
- CAssessing the client's lips for dryness評估病人嘴唇是否乾燥
- DUsing a soft-bristled toothbrush to clean teeth使用軟毛牙刷清潔牙齒
— Explanation · 中文詳解 —
吞嚥困難病人的口腔護理重點在於防止吸入性肺炎。使用大量的水沖洗會增加嗆入氣道的風險，因此應使用海綿棒沾少量水或避免大量液體進入口腔。高坐姿（High Fowler's）能降低吸入風險，軟毛刷與唇部評估均為正確照護行為。
Using large amounts of water for oral rinsing in a client with dysphagia poses a high risk of aspiration and subsequent pneumonia. The assistive personnel should use small amounts of moisture or sponge swabs instead, whereas positioning the client upright and using soft-bristled brushes are safe and appropriate practices.
✦ 台美臨床差異
美國由 AP 執行口腔護理的頻率極高；台灣多由護理師親自觀察或由家屬協助，故護理師對 AP 的督導責任需更具警覺性。