護理師準備餵食一位有高度吸入性肺炎風險的病人。下列哪項措施最優先？
A nurse is preparing to feed a client who is at high risk for aspiration. Which action is the priority?
- ACheck the client's gag reflex檢查病人的嘔吐反射
- BPerform oral hygiene before the meal餐前進行口腔護理
- CPosition the client upright at a 90-degree angle✓ 正解將病人置於九十度直立姿勢
- DEnsure the diet consists of clear liquids確保飲食由清流質組成
對於有吸入性肺炎（Aspiration）風險的病人，利用重力（Gravity）是防止食物或液體進入氣管的最有效物理手段。將床頭抬高至 90 度（High-Fowler's position）可確保食道處於垂直位置，降低逆流風險。在執行任何餵食動作前，確保病人姿勢正確是安全護理的優先考量（Safety/ABC原則）。
Positioning the client upright at a 90-degree angle utilizes gravity to keep food and liquid in the stomach, significantly reducing the risk of aspiration. While checking the gag reflex and performing oral hygiene are important supportive measures, proper positioning is the priority intervention to ensure airway safety during feeding. Clear liquids pose a higher aspiration risk than thickened liquids, making this option incorrect.
美國臨床中，對於有吞嚥困難的病人，通常會諮詢言語治療師（Speech-Language Pathologist, SLP）進行吞嚥功能評估（Bedside Swallow Evaluation），護理師需嚴格執行 SLP 建議的擺位與飲食質地（如 IDDSI 標準），此點與台灣臨床邏輯一致。