[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-106-2-fundamental-nursing-036":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":63},"基本護理學與護理行政","fundamental-nursing","基本護理學(包括護理原理、護理技術)與護理行政",{"id":8,"webId":9,"year":10,"session":11,"subject":4,"number":12,"stem":13,"options":14,"answer":19,"answerNote":20,"images":21,"explanation":22,"explanationDeep":23,"topics":24,"freq":27},"nurse-106-2-基本護理學與護理行政-036","nurse-106-2-fundamental-nursing-036",106,2,36,"蔣奶奶 16 小時未解尿，膀胱脹，經誘尿無效需導尿。下列護理措施何者較不適當？",{"A":15,"B":16,"C":17,"D":18},"可採用單次導尿","選擇 14 Fr.導尿管","導尿管插入 5 公分","一次導出所有尿液","D",null,[],"本題考點是急性尿滯留導尿的安全原則。依膀胱減壓生理,長時間脹滿的膀胱若一次快速排空大量尿液,腔內壓驟降會使黏膜血管充血破裂而血尿,並可能引發迷走神經反射性低血壓,故應分段緩慢導出,「一次導出所有尿液」為較不適當,選 D。A 蔣奶奶為暫時性尿滯留,採單次(直入式)導尿即可,適當;B 成人一般選 14 Fr. 導尿管口徑適中,適當;C 女性尿道短,導尿管插入約 5～7.5 公分見尿即可,插入 5 公分適當。唯 D 忽略減壓安全。","傳統護理教科書建議膀胱過度膨脹時,首次導出以不超過約 800～1000 mL 為限,其餘夾管休息片刻再放,以防『減壓性血尿』與姿勢性低血壓。近年部分實證對分段導尿的必要性有討論,但國考仍以分次緩放為標準答案。可連結至留置與單次導尿適應症、導尿管 French 尺碼概念。",[25,28,30,32],{"term":26,"count":27},"急性尿滯留",1,{"term":29,"count":27},"膀胱分段減壓",{"term":31,"count":27},"減壓性血尿",{"term":33,"count":27},"導尿管 French 尺碼",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-106-2-fundamental-nursing-037","有關醫療環境中機械性傷害之敘述，下列何者正確？",37,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-107-1-fundamental-nursing-053","宋女士 52 歲，乳癌末期，因癌細胞侵犯神經導致下半身無力，宗教信仰為基督教，某日眼泛淚光地對護理師說：「如果神愛我，為何將我困在這樣的身體裡？」，當下護理師何種應對最為適切？",53,107,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-107-2-fundamental-nursing-067","病房應用日常生活活動量表將病人生理需求予以計分，護理活動則依計分點數分類病人。此為下列何種分類法？",67,{"webId":49,"stem":50,"number":51,"year":52,"session":27},"nurse-109-1-fundamental-nursing-025","黃先生的血液檢驗報告：Sodium 141 mEq\u002FL、Potassium 2.7 mEq\u002FL、Chloride 100 mEq\u002FL、Calcium 5.1 mEq\u002FL，依據此檢驗報告，下列護理衛教措施，何者最適當？",25,109,{"webId":54,"stem":55,"number":56,"year":57,"session":27},"nurse-110-1-fundamental-nursing-069","使用多項護理人力的彈性運用策略，以解決護理人力短缺問題，下列何者屬於「數量彈性」？",69,110,{"webId":59,"stem":60,"number":61,"year":62,"session":11},"nurse-111-2-fundamental-nursing-023","如果注射部位周圍皮膚冰冷、腫脹、有壓痛感，輸注速度變慢現象時，下列處理方法何者最適當？ ①停止輸注 ②局部濕熱敷 ③給予解熱藥物 ④重新更換注射部位 ⑤按摩注射部位",23,111,"2026-09-04",1788510697761]