[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-107-2-fundamental-nursing-021":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":33,"lastmod":62},"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-107-2-基本護理學與護理行政-021","nurse-107-2-fundamental-nursing-021",107,2,21,"小可是一個妊娠週數 32 週的早產兒，目前體重 1.8 kg，有低血糖情形，給與 12.5% glucose water 靜脈輸注中。小可因血紅素過低，依醫囑輸血，輸血後 10 分鐘出現發燒、心搏過速、低血壓、血尿等情形，下列護理措施何者須優先執行？",{"A":15,"B":16,"C":17,"D":18},"保留輸血裝置與採集血液送檢驗","請值班醫師開醫囑給藥","停止輸血，以 0.9% NaCl 維持靜脈通暢","記錄輸出入量","C",null,[],"本題考點為輸血反應發生時的優先護理措施。個案輸血後 10 分鐘即出現發燒、心搏過速、低血壓、血尿，屬急性輸血反應，依處置原則首要動作是立即停止輸血，並改以 0.9% NaCl(生理食鹽水)維持靜脈通暢，故選 C。A 保留輸血裝置與採血送檢是後續確認反應原因的步驟，須在停血後進行。B 通知醫師開立醫囑固然重要，但不能凌駕先停止致害輸血。D 記錄輸出入量屬常規紀錄，非危急當下的優先順序。","輸血反應處置口訣：停(停輸血)、換(換生理食鹽水，不可用含糖或含鈣點滴以免溶血或凝集)、查(核對病人與血袋)、留(保留血袋與輸血套送檢)、報(通知醫師)。生理食鹽水為等張且不含葡萄糖與鈣，是唯一可與血液共用管路的溶液，此為必考安全概念。",[25,28,31],{"term":26,"count":27},"輸血反應處置",3,{"term":29,"count":30},"停止輸血優先",1,{"term":32,"count":30},"生理食鹽水維持靜脈通暢",[34,38,43,47,52,57],{"webId":35,"stem":36,"number":37,"year":10,"session":11},"nurse-107-2-fundamental-nursing-022","承上題，小可出現的是何種輸血副作用？",22,{"webId":39,"stem":40,"number":41,"year":42,"session":30},"nurse-108-1-fundamental-nursing-038","下列那一因素會造成血壓下降？",38,108,{"webId":44,"stem":45,"number":46,"year":42,"session":11},"nurse-108-2-fundamental-nursing-052","腦死判定時，有關腦幹反射功能的測試應包括下列何者？",52,{"webId":48,"stem":49,"number":50,"year":51,"session":30},"nurse-110-1-fundamental-nursing-010","有關病人的資料收集及觀察時機，下列敘述何者正確？",10,110,{"webId":53,"stem":54,"number":55,"year":56,"session":30},"nurse-111-1-fundamental-nursing-054","有關臨終照護的敘述，下列何者錯誤？",54,111,{"webId":58,"stem":59,"number":60,"year":61,"session":11},"nurse-112-2-fundamental-nursing-008","承上題，關於林護理師所運用的技巧，下列敘述何者正確？",8,112,"2026-09-04",1788510724299]