[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-108-1-fundamental-nursing-034":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-108-1-基本護理學與護理行政-034","nurse-108-1-fundamental-nursing-034",108,1,34,"病人因下腹劇痛數日且盜冷汗入院，主訴已有一週未解便，下列護理師的措施何者較不適當？",{"A":15,"B":16,"C":17,"D":18},"評估病人過去排便型態","執行腹部視聽叩及輕觸診","詢問目前是否使用止痛藥","立即給予肥皂水清潔灌腸","D",null,[],"本題考點是急性腹痛合併疑似腸阻塞時的護理禁忌。判斷依據是「病因未明、疑有腸阻塞前不可灌腸」:病人下腹劇痛、盜冷汗且一週未解便,高度懷疑腸阻塞或急性腹症,此時若灌腸會增加腸腔壓力、可能造成腸穿孔或加重病情,故D立即給予肥皂水清潔灌腸最不適當,選D。A評估過去排便型態是收集基本資料、判斷問題來源,適當;B執行腹部視、聽、叩、觸診依序評估腸蠕動音與壓痛,是正確評估順序;C詢問止痛藥使用可了解疼痛與藥物影響(如鴉片類致便秘),亦屬合理評估。三個正確選項都屬「先評估後處置」,唯D在病因未明下貿然侵入性處置,違反安全原則。","腹部評估的正確順序是視診→聽診→叩診→觸診,聽診必須先於叩觸診,以免刺激腸道改變腸音判讀,這與其他身體系統評估順序不同,是常考陷阱。急性腹症的護理紅旗:未確診前禁灌腸、禁瀉劑、禁止痛(以免遮蔽症狀),須先禁食並等待影像與醫療評估。可連結腸阻塞病生理(近端脹氣、腸壁缺血)與便秘處置的先後順序一併記憶。",[25,28,30,32],{"term":26,"count":27},"腸阻塞",2,{"term":29,"count":11},"腹部評估順序",{"term":31,"count":11},"急性腹症",{"term":33,"count":11},"灌腸禁忌",[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-108-1-fundamental-nursing-035","協助病人更衣的步驟，下列敘述何者正確？",35,{"webId":40,"stem":41,"number":42,"year":10,"session":27},"nurse-108-2-fundamental-nursing-051","護理師告知入院病人相關的權利敘述中，不包含下列何者？",51,{"webId":44,"stem":45,"number":46,"year":47,"session":11},"nurse-109-1-fundamental-nursing-065","在醫院組織結構中，下列何者不是集權（Centralization）的優點？",65,109,{"webId":49,"stem":50,"number":51,"year":52,"session":27},"nurse-110-2-fundamental-nursing-023","王先生身體外觀瘦弱，右小腿有一處 2×3 公分的傷口，左側偏癱無法行走，無法自行進食，有中度脫水情形。王先生的問題，下列何者應最優先處理？",23,110,{"webId":54,"stem":55,"number":56,"year":57,"session":27},"nurse-111-2-fundamental-nursing-067","有關組織管轄幅度的設計，下列敘述何者正確？",67,111,{"webId":59,"stem":60,"number":61,"year":62,"session":63},"nurse-112-3-fundamental-nursing-021","病人身上有中央靜脈導管及左手留置靜脈管路，協助更衣方式，下列敘述何者最適當？",21,112,3,"2026-09-04",1788510709051]