[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-109-1-fundamental-nursing-022":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-109-1-基本護理學與護理行政-022","nurse-109-1-fundamental-nursing-022",109,1,22,"護理師給予瀉劑 Bisacodyl 塞劑前，個案主訴腹絞痛，並冒冷汗不適，下列處置何者適當？",{"A":15,"B":16,"C":17,"D":18},"請個案哈氣，迅速將藥物推入肛門內","將藥物緩緩塞入，用衛生紙壓住肛門口","立即停止給藥，並觀察生命徵象","請個案深呼吸，並告知此為正常反應","C",null,[],"本題考點在於給藥過程出現異常反應時的處置優先順序。個案在給予Bisacodyl塞劑前即主訴腹絞痛、冒冷汗不適,屬非預期的異常徵象,可能與迷走神經反射或腹部急症有關,依病人安全與變化評估原則,應立即停止給藥並觀察生命徵象,選項C正確。選項A迅速推入藥物、B緩緩塞入並壓住肛門口,均在異常狀況下仍執意給藥、忽略先確認病情;D請個案深呼吸並告知為正常反應,錯在把冒冷汗等警訊誤判為正常,故選C。","給藥五對之外,更高原則是『用藥中出現非預期反應先停藥再評估』。冷汗、腹絞痛可能為迷走神經性反應(可致心搏過緩、低血壓)或潛在腹部急症的警訊,貿然給瀉劑恐加重。安全處置流程:停—評估生命徵象—通報醫師—記錄。",[25,28,31,33],{"term":26,"count":27},"病人安全",17,{"term":29,"count":30},"迷走神經反射",3,{"term":32,"count":30},"生命徵象評估",{"term":34,"count":11},"給藥異常反應處置",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-109-1-fundamental-nursing-023","Ampicillin（500mg）1 vial 粉劑藥物，病人需 Ampicillin 250 mg iv，備藥過程下列何者正確？",23,{"webId":41,"stem":42,"number":43,"year":10,"session":44},"nurse-109-2-fundamental-nursing-039","一位心房纖維震顫病史的病人，其橈動脈 52 次／分鐘、搏動規律，病人無感到頭暈及疲倦，為了確認病人是否出現脈搏短絀的問題，下列何者為最適當之立即性處置？",39,2,{"webId":46,"stem":47,"number":48,"year":49,"session":11},"nurse-110-1-fundamental-nursing-053","有關安寧緩和療護之敘述，下列何者正確？",53,110,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-111-2-fundamental-nursing-011","病歷正確記錄的原則，下列何者錯誤？①大便次數的記錄是指該天一整天所解出的次數 ②疼痛指數的記錄以黑色實心圓記錄 ③輸出量包括大便、胸腔引流液量 ④灌腸後才解的大便次數以「1\u002FE」表示",11,111,{"webId":56,"stem":57,"number":58,"year":59,"session":44},"nurse-112-2-fundamental-nursing-055","有關臨終病人的護理措施，下列何者適當？",55,112,{"webId":61,"stem":62,"number":63,"year":64,"session":30},"nurse-113-3-fundamental-nursing-019","當脂肪取代醣類為身體能量的主要來源時，尿液中會出現那一種大量的物質？",19,113,"2026-09-04",1788510711814]