護理師準備為一位意識不清的病人執行口腔護理。哪項行動是安全優先？
The nurse is preparing to provide oral care to an unconscious client. Which action is a priority for safety?
- APlace the client in a side-lying position✓ 正解將病人置於側臥姿勢
- BBrush the teeth with a hard-bristle toothbrush使用硬毛牙刷刷牙
- CKeep the client in a supine position讓病人保持仰臥姿勢
- DUse a large amount of water to rinse the mouth使用大量水漱口
核心概念是預防意識不清病人（Unconscious client）發生吸入性肺炎（Aspiration pneumonia）。意識不清者缺乏正常的吞嚥反射與咳嗽反射，口腔內的唾液或護理時使用的液體極易進入氣管。將病人置於側臥位（Side-lying position，如 Sims position）能利用重力讓液體從嘴角流出，而非積聚在咽喉部。這是在執行口腔護理時最關鍵的安全優先（Safety priority）步驟，符合護理中「預防勝於治療」的原則。
Placing the client in a side-lying position is the priority safety action to prevent aspiration pneumonia, as it allows oral secretions to drain by gravity rather than pooling in the throat. Unconscious clients lack protective swallowing and coughing reflexes, making them highly susceptible to inhaling fluids or the tongue obstructing the airway. This positioning minimizes the risk of airway compromise during oral care procedures.
台美對預防吸入的重視程度一致。但在美國臨床，常規會使用「吸入性口腔護理包（Suction toothbrush kits）」，這種設備能一邊刷牙一邊抽吸，台灣則較常使用棉棒配合手動抽吸，NCLEX 考生需注意側臥位是姿勢上的唯一正確選擇。