— 基本照護與舒適 · HARD · SATA —
護理師照護一位放置鼻胃管（NG）的病人，下列哪些護理措施是正確的？（選所有適合的）
A nurse is caring for a client with a nasogastric (NG) tube. What are the appropriate nursing actions? (Select all that apply.)
- AVerify tube placement using pH testing of aspirate✓ 正解使用抽吸液的 pH 值檢測來確認管路位置
- BFlush the tube with 30 mL of water before and after medications✓ 正解在給藥前後用 30 mL 的水沖洗管路
- CAspirate gastric contents to check residuals every 4 hours每 4 小時抽吸胃內容物以檢查殘留量
- DKeep the head of the bed elevated at least 30 degrees✓ 正解將床頭抬高至少 30 度
- EUse force to clear a clogged tube用力清除堵塞的管路
— Explanation · 中文詳解 —
鼻胃管護理重點在於防止吸入性肺炎與維持通暢。抬高床頭（D）可預防逆流，確認 pH 值（A）是金標準，沖洗管路（B）可防阻塞。檢查殘餘量（C）目前已不再建議常規每 4 小時執行，除非有特殊臨床徵象。強行打通（E）可能導致管路破裂或食道損傷。
Proper nasogastric tube care includes verifying placement via pH testing, keeping the head of the bed elevated to prevent aspiration, and flushing with water to maintain patency. Routine checks for residual volume are no longer recommended, and forcing fluids through a clogged tube should be avoided to prevent mucosal damage.
✦ 台美臨床差異
台灣目前臨床仍傾向監測殘餘量，但美國護理照護指引已多數排除「每 4 小時常規殘餘量檢查」。