[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-107-2-fundamental-nursing-053":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":65},"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-053","nurse-107-2-fundamental-nursing-053",107,2,53,"劉奶奶，75 歲，肝硬化末期，腹水、雙下肢水腫 3＋，病情惡化處於臨終階段，進食量減少，家屬非常擔心病人會餓死，下列護理處置何者最不適當？",{"A":15,"B":16,"C":17,"D":18},"用海綿牙棒沾茶葉水協助病人口腔護理","鼓勵家屬用言語與肢體表達愛與關心，不勉強病人進食","同理家屬的擔憂，並告知此為正常瀕死症狀","與醫師討論增加點滴輸液量，並抽血監測白蛋白數值","D",null,[],"本題考點在臨終病人進食減少的舒適照護。依安寧緩和原則，瀕死期食慾與進食下降是自然歷程，此時積極補充水分與營養並無法逆轉病程，反而可能加重負擔，故 D「與醫師討論增加點滴補液量並抽血監測白蛋白」最不適當，選 D。劉奶奶已有腹水與雙下肢水腫 3＋，過度補液會加劇體液滯留與呼吸負擔。A 以海綿棒沾茶水做口腔護理可緩解口乾不適，適當。B 鼓勵家屬表達關愛、不勉強進食，尊重自然歷程，適當。C 同理家屬擔憂並說明此為正常瀕死症狀，適當。三者皆重舒適，唯 D 屬過度介入。","臨終脫水（terminal dehydration）在安寧照護中被視為自然且可能減輕痛苦：可減少呼吸道分泌物、肺水腫、腹水與周邊水腫，降低喘與咳。過度靜脈補液對已有腹水、水腫、低白蛋白（肝硬化）者風險更高。照護焦點轉為症狀控制與舒適：濕潤口腔、翻身減壓、陪伴。抽白蛋白等監測性檢查對已決定安寧者意義有限。口訣：「臨終照顧看舒適，不看數值追指標」。",[25,28,31,33],{"term":26,"count":27},"安寧緩和照護",5,{"term":29,"count":30},"臨終脫水",1,{"term":32,"count":30},"體液滯留與腹水",{"term":34,"count":30},"舒適照護目標",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-107-2-fundamental-nursing-054","有關需要長期照護病人之出院返家準備，下列何者錯誤？",54,{"webId":41,"stem":42,"number":43,"year":44,"session":30},"nurse-108-1-fundamental-nursing-070","下列那一項疾病不是藉由媒介物傳染？",70,108,{"webId":46,"stem":47,"number":48,"year":49,"session":30},"nurse-109-1-fundamental-nursing-004","生命徵象的記錄表單中，在 TPR 以下的欄位所記錄的事項不包括下列何者？",4,109,{"webId":51,"stem":52,"number":53,"year":54,"session":30},"nurse-110-1-fundamental-nursing-042","有關血壓的測量，下列敘述何者正確？",42,110,{"webId":56,"stem":57,"number":58,"year":59,"session":11},"nurse-111-2-fundamental-nursing-006","護理師評估病人所收集的資料，下列何者為症狀（symptom）？",6,111,{"webId":61,"stem":62,"number":63,"year":64,"session":11},"nurse-112-2-fundamental-nursing-040","急診室接到重大車禍傷患，到院時意識不清，血壓只有 70\u002F35 mmHg，懷疑內出血，下列敘述何者正確？",40,112,"2026-09-04",1788510724624]