— 基本照護與舒適 · MEDIUM · MCQ —
護理師照顧一位正接受持續管灌餵食的病人。哪項護理干預對於預防誤吸最為重要？
A nurse is caring for a client with a continuous tube feeding. Which nursing intervention is most important to prevent aspiration?
- AFlush the tube with 30 mL of water before and after feeding.在餵食前後以 30 mL 水沖洗管路
- BVerify the tube placement by auscultating air bolus.通過聽診氣泡音確認管路位置
- CKeep the head of the bed elevated at least 30 to 45 degrees.✓ 正解保持床頭抬高至少 30 至 45 度
- DCheck gastric residual volume every 4 hours.每 4 小時檢查胃殘餘量
— Explanation · 中文詳解 —
維持床頭抬高 30-45 度是預防管灌病人誤吸的最有效措施，利用重力防止胃內容物反流。雖然監測殘餘量（D）重要，但抬高床頭是持續性的物理防禦。聽診（B）已不再是確認位置的可靠方法（應以 X-ray 或 pH 為主）。
Elevating the head of the bed to at least 30 to 45 degrees is the most effective intervention for preventing aspiration during continuous tube feeding, as it utilizes gravity to keep gastric contents in the stomach. While checking gastric residuals and verifying tube placement are important safety measures, they do not actively prevent reflux as effectively as proper positioning.
✦ 台美臨床差異
美國目前傾向減少 GRV 監測頻率以避免管路阻塞；台灣仍普遍每 4 小時監測一次殘餘量。