[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-107-1-fundamental-nursing-017":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-107-1-基本護理學與護理行政-017","nurse-107-1-fundamental-nursing-017",107,1,17,"李先生手術後回到病房，手臂上留有靜脈滴注之管路，主訴疼痛程度為 8 分（用 0～10 分之疼痛評估量表），護理師查看醫囑單，醫囑為：「Demerol 40 mg q.4h. p.r.n. for pain」，依據病人目前情況及醫囑，護理師最適當的行動為何？",{"A":15,"B":16,"C":17,"D":18},"給予 Demerol 40 mg 肌肉注射","給予 Demerol 40 mg 靜脈注射","稍後再重新評估病人疼痛情形","聯絡醫師澄清及確認醫囑","D",null,[],"本題考點為醫囑澄清與給藥途徑安全。依給藥原則,醫囑『Demerol 40 mg q.4h. p.r.n. for pain』僅載明藥物、劑量、頻次與適應症,並未指明給藥途徑(I.M. 或 I.V.);途徑未明時護理師不可自行認定,應聯絡醫師澄清確認醫囑後再執行,故選 D。A、B 在途徑未確認下逕行肌注或靜注違反給藥安全;C 病人疼痛已達 8 分(中重度)且有 p.r.n. 止痛醫囑,延後再評估等於延誤止痛,不當,故非答案。","解題核心是『醫囑完整性』:一則合格給藥醫囑須含藥名、劑量、途徑、頻次(必要時含適應症),缺任一要素(此題缺途徑)即為不完整醫囑,護理師的專業責任是釐清而非自行填補。這體現病人安全與『不執行不清楚\u002F不完整醫囑』的守則。同時病人疼痛 8\u002F10 顯示有立即處置需求,故不能被動延後(排除 C),但也不能帶著疑義冒然給藥(排除 A、B),唯一兼顧安全與時效的是即刻聯絡醫師澄清。可連結疼痛量表(0–10 分,≥7 為重度)判讀處置急迫性。",[25,28,30,32],{"term":26,"count":27},"給藥安全",9,{"term":29,"count":11},"醫囑完整性(缺給藥途徑)",{"term":31,"count":11},"醫囑澄清",{"term":33,"count":11},"疼痛評估量表(0–10 分)",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-107-1-fundamental-nursing-018","張先生為第 2 型糖尿病病人，醫囑「RI（Regular Insulin）6U. S.C. a.c. t.i.d.」，下列敘述何者錯誤？",18,{"webId":40,"stem":41,"number":42,"year":10,"session":43},"nurse-107-2-fundamental-nursing-034","嬰幼兒進行清潔灌腸時，為避免產生體液電解質不平衡，選用下列何種溶液最適宜？",34,2,{"webId":45,"stem":46,"number":47,"year":48,"session":11},"nurse-108-1-fundamental-nursing-048","有關繃帶與束帶的敘述，下列何者錯誤？",48,108,{"webId":50,"stem":51,"number":52,"year":53,"session":43},"nurse-109-2-fundamental-nursing-006","病歷的生命徵象紀錄表中不會出現下列何種資料？",6,109,{"webId":55,"stem":56,"number":57,"year":58,"session":43},"nurse-110-2-fundamental-nursing-050","醫囑每 2 小時間歇管灌食的病人，已於 8：00 am 灌食 250 mL 後，於 10：00 am 管灌前反抽鼻胃管有 150 mL 之未消化液，下列處置何者最適當？",50,110,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-112-1-fundamental-nursing-004","影響健康的相關因素，下列敘述何者錯誤？",4,112,"2026-09-04",1788510701844]