— 照護管理 · MEDIUM · MCQ —
護理師照護一位接受機械通氣的病人，下列哪項措施最能預防呼吸器相關肺炎（VAP）？
A nurse is caring for a client who is receiving mechanical ventilation. Which intervention is most critical for preventing ventilator-associated pneumonia (VAP)?
- AMaintain the head of the bed elevated at 30-45 degrees✓ 正解維持床頭抬高 30-45 度
- BAdminister sedation as prescribed依處方給予鎮靜劑
- CChange the ventilator circuit every 48 hours每 48 小時更換呼吸器管路
- DProvide routine oral care with chlorhexidine使用氯己定進行常規口腔護理
— Explanation · 中文詳解 —
預防呼吸器相關肺炎（VAP）的核心措施之一是將床頭抬高 30-45 度。這能利用重力防止胃內容物或口腔分泌物逆流至氣管和肺部，有效降低吸入風險。其他措施如定期口腔照護（使用 Chlorhexidine）亦極為重要，但抬高床頭是基礎且最有效的物理性預防方法。鎮靜（B）過度反而不利於自主呼吸功能；更換管路（C）無須頻繁至 48 小時。
Elevating the head of the bed to 30-45 degrees is a critical intervention for preventing ventilator-associated pneumonia as it uses gravity to reduce the risk of aspiration. While oral care is beneficial, maintaining proper body alignment is the foundational physical measure to prevent gastric contents from entering the lungs.