— 基本照護與舒適 · HARD · MCQ —
鼻胃管病人出現何種徵象，顯示管路可能已滑入呼吸道？
Which assessment finding in a client with a nasogastric (NG) tube indicates that the tube may have migrated into the respiratory tract?
- APresence of brownish drainage from the tube管路有咖啡色引流液
- BIncreased amount of gastric residual volume胃殘留量增加
- CDifficulty speaking clearly說話不清
- DSudden onset of coughing and dyspnea✓ 正解突然發作的咳嗽與呼吸困難
— Explanation · 中文詳解 —
鼻胃管（NG tube）置入過程中，最嚴重的併發症是誤入氣道。當管路進入呼吸道，會刺激氣管與支氣管黏膜，引起劇烈咳嗽、呼吸困難、發紺（cyanosis）及氧氣飽和度下降。護理師在給藥或灌食前，必須確實執行管路位置確認（如測量 pH 值、X 光確認），若出現上述呼吸道症狀，應立即暫停並移除或重新安置。
If a nasogastric tube migrates into the respiratory tract, it will irritate the airway mucosa. This typically presents as sudden coughing, dyspnea, or cyanosis, indicating the need to stop administration and verify tube placement immediately.