— 基本照護與舒適 · MEDIUM · MCQ —
護理師準備餵食一位有吸入性肺炎風險的病人。為維護安全，下列哪項行動優先級最高？
A nurse is preparing to feed a client who is at risk for aspiration. Which action is the highest priority to maintain safety during feeding?
- AOffer small, frequent sips of water throughout the meal在進餐期間提供少量多次的水
- BEnsure the client can swallow before initiating the meal確保病人在開始進食前能夠吞嚥
- CCheck for residual gastric volume before feeding餵食前檢查胃殘留量
- DPlace the client in an upright position at 90 degrees✓ 正解將病人置於 90 度的直立姿勢
— Explanation · 中文詳解 —
對於吸入風險高的病人，姿勢調整是預防誤吸的第一防線。將床頭抬高 90 度（坐姿）能利用重力防止食物逆流進入呼吸道。檢查殘餘量（C）多針對管灌，而非一般餵食；評估吞嚥功能（B）重要但姿勢即刻決定安全；補水（A）需視吞嚥能力而定。
Positioning is the primary defense against aspiration; placing the client in an upright 90-degree position uses gravity to keep food in the stomach. While swallowing assessments are important, immediate safety during feeding relies on proper posture. Checking gastric residuals applies to tube feeding, and offering water without assessing swallow function increases risk.
✦ 台美臨床差異
美台臨床皆強調高坐姿，但在台灣，跨領域團隊（如吞嚥職能治療）介入較晚，護理師需更多依賴評估工具。