— 基本照護與舒適 · HARD · MCQ —
一位病人需要口腔護理協助，但其嘔吐反射受損。護理師的優先顧慮為何？
A client requires assistance with oral hygiene but has an impaired gag reflex. What is the nurse's priority concern?
- APreventing aspiration✓ 正解防止吸入
- BMaintaining privacy during the procedure在進行程序期間維持隱私
- CEnsuring the client's mouth is completely dry確保病人嘴巴完全乾燥
- DChecking the client's teeth for cavities檢查病人牙齒是否有蛀牙
— Explanation · 中文詳解 —
嘔吐反射（Gag reflex）是保護呼吸道免受異物侵入的重要機制。當該反射受損時，病人在口腔護理過程中，極易因吞入清潔液或脫落的牙垢而導致誤吸，進而引發吸入性肺炎。因此，預防誤吸（Aspiration）是護理師在進行口腔清潔時的最高優先級（Priority），必須採取側臥位或限制水分使用來確保氣道安全。
The priority concern is preventing aspiration because an impaired gag reflex removes the body's natural defense against foreign objects entering the airway. During oral hygiene, fluids or debris can easily be inhaled, leading to aspiration pneumonia, which poses an immediate life-threatening risk.