[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-108-2-medical-surgical-065":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":36,"lastmod":65},"內外科護理學","medical-surgical",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-108-2-內外科護理學-065","nurse-108-2-medical-surgical-065",108,2,65,"蔡先生主訴噁心、食慾不振，昨日嘔吐量約 150 c.c.\u002F天，排尿量 360 c.c.\u002F天，血清鉀 6.8 mEq\u002FL，下列處置何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"液體攝入量應限制在 510 c.c.\u002F天","給予 furosemide（lasix）引發利尿","給予 kayexalate 降低血鉀濃度","應採高熱量、低蛋白、低鹽飲食","A",null,[],"本題考點為急性腎衰竭少尿期合併高血鉀的處置正確性判斷。臨床限水量常以「前一日總排出量加不感性失水(約 500 mL)」估算，本病人前日尿量 360 mL 加嘔吐 150 mL 再加不感性失水約 500 mL，合理攝入量應約 1000 mL 左右，故將液體攝入限制在 510 c.c.\u002F天過度嚴苛、屬錯誤處置，選 A。選項 B 給予 furosemide 促進利尿與排鉀，適用於少尿期試圖增加尿量。選項 C 給予 kayexalate(陽離子交換樹脂)可經腸道置換排出鉀離子、降血鉀，正確。選項 D 高熱量、低蛋白、低鹽飲食可減少含氮廢物與鈉水負荷，為腎衰竭正確飲食原則。故錯誤者為限水過低。","腎衰竭限水公式：允許攝入 ≈ 前日尿量 + 其他失水(嘔吐、引流) + 不感性失水(約 500-800 mL)。血鉀 6.8 屬危急，處置優先序含穩定心肌(鈣)、鉀移入細胞(胰島素加葡萄糖、碳酸氫鈉、β 促效劑)、排除鉀(利尿劑、kayexalate、透析)。飲食低蛋白降氮質、低鉀低鈉低磷。判題抓「限水數字是否合理」。",[24,27,30,32,34],{"term":25,"count":26},"高血鉀處置",4,{"term":28,"count":29},"少尿期限水計算",1,{"term":31,"count":29},"furosemide 利尿",{"term":33,"count":29},"kayexalate 陽離子交換樹脂",{"term":35,"count":29},"低蛋白飲食",[37,41,45,50,55,60],{"webId":38,"stem":39,"number":40,"year":9,"session":10},"nurse-108-2-medical-surgical-066","有關腎盂腎炎的敘述，下列何者錯誤？",66,{"webId":42,"stem":43,"number":10,"year":44,"session":10},"nurse-109-2-medical-surgical-002","有關頭部外傷病人經手術取出顱內血腫並於腦室內放置顱內壓監測器（ICP monitoring device）之敘述，下列何者錯誤？",109,{"webId":46,"stem":47,"number":48,"year":49,"session":29},"nurse-110-1-medical-surgical-016","有關膽道疾病手術後放置 T 型管的護理措施，下列何者錯誤？",16,110,{"webId":51,"stem":52,"number":53,"year":54,"session":29},"nurse-111-1-medical-surgical-054","病人行氣管內插管後聽診呼吸音時，發現左側肺部呼吸音減弱但右側正常，下列何者為導致此情形最可能的原因？",54,111,{"webId":56,"stem":57,"number":58,"year":59,"session":10},"nurse-112-2-medical-surgical-018","右小腿上石膏病人，出現下列何項臨床表徵，需要立即給予處理？",18,112,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-113-2-medical-surgical-032","有關鞏皮症（進行性系統性硬化症，progressive system sclerosis）護理指導之敘述，下列何者錯誤？",32,113,"2026-09-04",1788510706737]