— 基本照護與舒適 · MEDIUM · MCQ —
護理師為一位意識不清的病人執行口腔護理，最重要的考量是什麼？
A nurse is providing hygiene care to an unconscious client. What is the priority concern during oral care?
- AEnsuring the client's mouth smells pleasant確保病人口腔氣味清新
- BStimulating the client's gum tissue刺激病人的牙齦組織
- CRemoving all dental plaque清除所有牙菌斑
- DPreventing aspiration✓ 正解預防吸入性肺炎
— Explanation · 中文詳解 —
針對意識不清（unconscious）的病人，護理的核心原則在於維持呼吸道通暢（airway patency）並預防吸入性肺炎（aspiration pneumonia）。由於病人缺乏吞嚥反射，口腔護理時若處理不當，液體極易流向氣管，造成嚴重的併發症。臨床上應將病人擺位至側臥（side-lying）位置，並限制使用液體量，必要時使用吸痰管輔助，隨時監測呼吸狀況。
The priority concern during oral care for an unconscious client is preventing aspiration due to diminished protective reflexes. The nurse must position the client appropriately and limit fluid volume to ensure the airway remains safe while cleaning the mouth.