— 基本照護與舒適 · MEDIUM · MCQ —
護理師為無意識病人執行口腔清潔。最重要考量是什麼？
A nurse is performing oral hygiene for an unconscious client. What is the most important consideration?
- AEnsuring the client's teeth are brushed for 5 minutes確保病人的牙齒刷滿 5 分鐘
- BUsing a lemon-glycerin swab for fresh breath使用檸檬甘油棒以清新口氣
- CKeeping the client's mouth wide open with a metal spatula以金屬壓舌板保持病人嘴巴張開
- DPreventing aspiration✓ 正解防止吸入性肺炎
— Explanation · 中文詳解 —
對於無意識病人，保護呼吸道安全（Airway safety）是所有護理介入的最高指導原則。由於病人缺乏咳嗽反射與吞嚥反射，口腔清潔時若液體過多或體位不當，極易發生吸入性肺炎（Aspiration pneumonia）。執行口腔護理時，應採取側臥位（Side-lying position）以利液體流出，並使用抽吸器（Suction）維持口腔乾燥。
For an unconscious client, preventing aspiration is the highest priority because they lack protective cough and swallow reflexes. Positioning the client on their side and using suction ensures that secretions or fluids do not enter the airway, thereby maintaining airway safety during oral hygiene.