— 基本照護與舒適 · MEDIUM · MCQ —
護理師照顧放置鼻胃管灌食的病人，為預防吸入性肺炎，哪項處置最優先？
A nurse is caring for a client with a nasogastric tube for enteral feeding. Which action is the priority to prevent aspiration?
- AWarm the formula to room temperature將配方奶加熱至室溫
- BVerify tube placement by checking gastric pH透過檢查胃液 pH 值來確認管子的位置
- CElevate the head of the bed to at least 30 to 45 degrees✓ 正解將床頭抬高至少 30 至 45 度
- DFlush the tube with 30 mL of water before feeding在灌食前以 30 mL 的水沖洗管子
— Explanation · 中文詳解 —
防止吸入性肺炎最關鍵的動作是維持體位。將床頭抬高 30-45 度可利用重力避免胃內容物逆流至食道與呼吸道。雖然檢查管路位置（B）很重要，但臨床上床頭抬高才是防止誤吸的最直接物理屏障。沖水和加熱僅是為了管路通暢與舒適度，並非防吸入的核心。
According to standard guidelines for low-risk pregnancies, prenatal visits should occur every four weeks during the first 28 weeks of gestation. This schedule allows for regular monitoring of maternal and fetal health without being overly frequent. Visit frequency typically increases to every two weeks after 28 weeks and weekly after 36 weeks.
✦ 台美臨床差異
美國多強調留置管路前的 X 光驗證，台灣常規以聽診或抽吸胃液確認位置，但床頭抬高原則兩者一致。