— 基本照護與舒適 · HARD · MCQ —
一位瀕死個案出現死亡喉音（瀕死呼吸音），護理師最適當的措施為何？
A nurse is caring for a client who is terminally ill and experiencing death rattle (noisy breathing). Which nursing action is most appropriate?
- AStart intravenous antibiotics開始靜脈注射抗生素
- BAdminister high-flow oxygen給予高流量氧氣
- CPerform aggressive tracheal suctioning執行積極的氣管抽吸
- DTurn the client to the side✓ 正解將病人轉為側臥
— Explanation · 中文詳解 —
瀕死期的死亡喉音（death rattle）是由於病人失去吞嚥反射，導致唾液與支氣管分泌物在咽喉處堆積所產生的雜音。這在臨終照護中非常常見。採取側臥位（side-lying position）可利用重力作用，促進分泌物引流，從而減輕呼吸雜音。積極抽吸通常會引發病人不適且效果短暫，對於緩解症狀的效益極低。
Death rattle results from the accumulation of secretions due to the loss of swallowing reflexes in terminally ill clients. Repositioning the client to a side-lying position uses gravity to facilitate drainage and reduce noisy breathing, while aggressive suctioning is generally avoided as it causes discomfort with minimal benefit.