[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-108-2-fundamental-nursing-040":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":63},"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-108-2-基本護理學與護理行政-040","nurse-108-2-fundamental-nursing-040",108,2,40,"雙手尺骨骨折的病人，手術後 6 小時未解尿，觸診膀胱鼓脹，下列何者是最適當的獨立性護理功能？",{"A":15,"B":16,"C":17,"D":18},"進行單次導尿","讓病人手握冰塊","按摩恥骨聯合上方","給予局部用熱","C",null,[],"本題考點為術後尿滯留的「獨立性護理功能」與導尿的權責界線。獨立性護理功能指護理師依專業判斷可自行執行、不需醫囑者。膀胱鼓脹的誘尿措施中,按摩恥骨聯合上方(膀胱區、Credé手法)可刺激膀胱收縮、協助排尿,屬護理師可自主執行的獨立性措施,選C。A單次導尿為侵入性技術、須醫囑,屬合作性功能。B讓病人手握冰塊缺乏促進排尿的依據。D局部用熱雖有助放鬆,但相較之下按摩膀胱區為更直接的誘尿獨立措施。先採非侵入性誘尿、無效再依醫囑導尿,是尿滯留的處理順序。","尿滯留的非侵入性誘尿(獨立性護理措施):聽流水聲、溫水沖會陰、下腹熱敷、按摩膀胱區(Credé手法由上往恥骨方向輕推)、提供隱私與正常排尿姿勢、開水龍頭以聽覺誘發。侵入性導尿(單次或留置)屬合作性\u002F依賴性功能,須醫囑並嚴守無菌。護理功能三分:獨立性(自主判斷執行)、合作性(與團隊協作,如依醫囑給藥)、依賴性(遵醫囑)。處理原則:先誘尿,無效且膀胱過脹才導尿,以免膀胱肌過度伸張受損。",[25,28,30,32],{"term":26,"count":27},"獨立性護理功能",1,{"term":29,"count":27},"尿滯留誘尿措施",{"term":31,"count":27},"Credé手法",{"term":33,"count":27},"導尿",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-108-2-fundamental-nursing-041","有關脊椎手術術後病人之移動與翻身擺位敘述，下列何者錯誤？",41,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-109-1-fundamental-nursing-057","護理長針對病房需改善的問題先提出初步方針後，再請護理同仁提出自己的意見及看法，然後由護理長做出決策。上述情況屬於下列何種決策模式？",57,109,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-109-2-fundamental-nursing-071","糖尿病病人住院時訂醫院的素食，但送餐有誤，營養部門進行檢討及改進，下列處理方法何者最不適當？",71,{"webId":49,"stem":50,"number":51,"year":52,"session":27},"nurse-111-1-fundamental-nursing-029","吳老先生住院多日未解便，醫囑給予意福灌腸液（EVAC enema）行小量灌腸，下列敘述何者正確？",29,111,{"webId":54,"stem":55,"number":56,"year":57,"session":27},"nurse-112-1-fundamental-nursing-073","有關控制（controlling）的基本概念，下列敘述何者正確？",73,112,{"webId":59,"stem":60,"number":61,"year":62,"session":11},"nurse-113-2-fundamental-nursing-007","有關病歷保存與管理的敘述，下列何者錯誤？",7,113,"2026-09-04",1788510705856]