[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-106-2-fundamental-nursing-053":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":64},"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-053","nurse-106-2-fundamental-nursing-053",106,2,53,"楊爺爺，72 歲，診斷為肺癌合併右肋、胸椎、骨盆等多處轉移，因疾病惡化處於瀕死階段，喉嚨發出臨終嘎音（death rattle），下列護理措施何者最適宜？",{"A":15,"B":16,"C":17,"D":18},"協助抽痰維持呼吸道通暢","給予背部叩擊促進痰液鬆動","依醫囑給予 hyoscine hydrobromide（Scopolamine）","協助 100%氧氣使用","C",null,[],"本題考點是瀕死病人臨終嘎音(death rattle)的處置。依成因,臨終嘎音是瀕死者意識與吞嚥反射衰退、無法清除咽喉唾液分泌物,氣流通過而發出的聲音;處理原則是「減少分泌物生成」,依醫囑給予抗膽鹼藥 hyoscine hydrobromide(Scopolamine)可抑制唾液腺分泌,故選 C。A 抽痰對瀕死病人是侵入性刺激、徒增痛苦且效果有限;B 背部叩擊會使病人不適,亦非針對唾液分泌;D 給予 100% 氧氣無法減少分泌物、對改善嘎音無實質幫助。唯 C 對症於分泌物過多的根本機轉。","臨終嘎音多困擾家屬更甚於病人本身(病人多已無意識、無窒息感)。抗膽鹼藥(Scopolamine、glycopyrrolate、atropine)透過阻斷 M 受體減少腺體分泌;搭配側臥擺位利分泌物引流。安寧照護強調『舒適為先、避免侵入』,積極抽痰反違此原則。可連結至臨終症狀控制與家屬預期性哀傷衛教。",[25,28,30,32],{"term":26,"count":27},"臨終嘎音 death rattle",1,{"term":29,"count":27},"抗膽鹼藥 Scopolamine",{"term":31,"count":27},"分泌物抑制",{"term":33,"count":27},"安寧舒適照護",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-106-2-fundamental-nursing-054","王小弟，4 歲，罹患罕見疾病，因多重併發症入院治療，其住院醫師目前正從事此疾病相關研究，要求護理師為病人抽血時，順便多留 5 c.c.血液檢體提供研究之用，護理師的回應下列何者最適宜？",54,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-107-1-fundamental-nursing-070","護理長將過去單位曾發生之意外疏失列入新進人員訓練之範疇，以避免再次發生病人照護安全的問題，此種問題解決法為：",70,107,{"webId":45,"stem":46,"number":47,"year":48,"session":27},"nurse-108-1-fundamental-nursing-004","對於一位正常成人尿液性狀之敘述，下列何者錯誤？",4,108,{"webId":50,"stem":51,"number":52,"year":53,"session":27},"nurse-109-1-fundamental-nursing-042","低蛋白質飲食適用於下列那些病人？①急性肺炎 ②肝昏迷 ③燒傷 ④尿毒症",42,109,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-110-2-fundamental-nursing-006","游奶奶接受雙側膝關節置換術，術後第一天使用自控式嗎啡疼痛控制器止痛，白班護生王同學照顧游奶奶，9:40 am 尚未備口服藥物，實習指導老師詢問下，王同學表示：「奶奶還在睡覺，剛剛測量的生命徵象 BP 為 122∕64 mmHg、TPR：36.4°C、64 次／分、8 次／分，我想奶奶昨天開刀應該讓她休息一下，我不忍心叫她起床吃藥」，針對上述情境，下列處置何者最適當？",6,110,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-111-2-fundamental-nursing-040","關於常見脈律不整類型的敘述，下列何者錯誤？",40,111,"2026-09-04",1788510697925]