— 基本照護與舒適 · HARD · SATA —
護理師為無意識病人進行口腔護理時，應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse take when providing oral care to an unconscious client? (Select all that apply.)
- APlace the client in a lateral position✓ 正解將個案置於側臥姿勢
- BUse a padded tongue blade to open the mouth✓ 正解使用墊有保護層的壓舌板張開嘴巴
- CUse lemon-glycerin swabs for cleaning使用檸檬甘油棉棒進行清潔
- DSuction secretions as needed✓ 正解視需要抽吸分泌物
- EAssess the oral mucosa for lesions✓ 正解評估口腔黏膜是否有病變
— Explanation · 中文詳解 —
無意識病人有誤吸風險，擺位應採側臥（側向護理師），有利於分泌物引流。使用撐口器（壓舌板）可防止咬傷護理人員；持續抽吸可避免窒息；檢查黏膜完整性是護理職責。檸檬甘油棉棒會導致黏膜乾燥且傷害口腔組織，應避免使用。
Oral care for unconscious clients requires positioning in a lateral side-lying posture to prevent aspiration of secretions. Suctioning should be performed as needed to maintain a clear airway, and the oral mucosa must be assessed for lesions. A padded tongue blade aids in safely opening the mouth, while lemon-glycerin swabs should be avoided as they cause mucosal drying and irritation.
✦ 台美臨床差異
在台灣臨床，口腔護理多由照服員協助，但護理師應評估並督導其技巧，防止誤吸發生。