— 基本照護與舒適 · HARD · MCQ —
一位接受持續管灌餵食的病人，哪項評估結果需要立即處置？
A nurse is caring for a client with a continuous tube feeding. Which assessment finding requires immediate action?
- AClient reports feeling full and bloated病人報告感到飽脹和腹脹
- BGastric residual volume of 100 mL胃殘餘量為 100 mL
- CAuscultation of crackles in the lower lobes of the lungs✓ 正解肺部下葉聽診出現囉音
- DFeeding pump alarm indicating a blockage餵食幫浦警報指示管路阻塞
— Explanation · 中文詳解 —
管灌餵食病人的首要安全考量為預防吸入性肺炎（Aspiration Pneumonia）。肺部聽診出現囉音（crackles）代表肺部可能有液體積聚，對於管灌病人而言，這高度警示可能發生了胃內容物逆流或吸入，屬於緊急情況。護理師需立即停止灌食、評估呼吸道通暢性、抬高床頭並通知醫師，這是 ABC（呼吸道、呼吸、循環）優先原則的具體體現。
Crackles in the lower lung lobes indicate potential aspiration, which is a life-threatening respiratory emergency requiring immediate intervention. The nurse must prioritize airway safety by stopping the feeding, assessing the client's breathing, and elevating the head of the bed.
✦ 台美臨床差異
美國臨床目前對於 GRV 的監控已趨向保守，許多醫院已取消常規檢測 GRV，除非病人出現腹脹或嘔吐等症狀，這與台灣部分醫院仍維持常規檢測有所不同。