— 基本照護與舒適 · MEDIUM · MCQ —
護理師為一位意識不清的病人進行口腔護理，下列哪項措施對預防吸入性肺炎至關重要？
A nurse is preparing to provide oral hygiene to a client who is unconscious. Which action is essential to prevent aspiration?
- APosition the client in a side-lying position✓ 正解將病人置於側臥位
- BApply generous amounts of water to the mouth with a syringe用注射器大量沖洗口腔
- CUse a toothbrush with stiff bristles for deep cleaning使用硬毛牙刷進行深度清潔
- DKeep the client in a supine position to ensure stability讓病人保持仰臥位以確保穩定
— Explanation · 中文詳解 —
意識不清的病人吞嚥反射減弱，側臥姿勢利用重力引流，使口腔內液體流出而非進入呼吸道，這是預防吸入性肺炎最有效的物理手段。硬毛刷可能損傷黏膜引起出血與感染；大量用水沖洗會增加嗆咳風險，應改用棉棒沾水擦拭。
Positioning an unconscious client in a side-lying position uses gravity to allow fluids to drain from the mouth, significantly reducing the risk of aspiration. This is safer than the supine position and avoids the hazards of flooding the mouth with large volumes of water.
✦ 台美臨床差異
美台皆強調口腔照護的預防吸入性肺炎機制，但台灣部分單位傾向使用特殊口腔護理包，需教導家屬使用方式。