[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-109-1-fundamental-nursing-053":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"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-109-1-基本護理學與護理行政-053","nurse-109-1-fundamental-nursing-053",109,1,53,"羅先生正在接受 D 5 W 靜脈輸注，流速為 180 mL\u002Fhour，羅先生主訴呼吸喘不舒服，護理師發現其頸靜脈怒張，下列措施何項最為優先？",{"A":15,"B":16,"C":17,"D":18},"通知醫師並報告輸注流速","協助羅先生採取半坐臥式","關閉管夾並移除靜脈輸注管路","調慢點滴流速保持靜脈通暢","D",null,[],"本題考點為靜脈點滴所致循環負荷過量的優先處置。180 mL\u002Fhr流速偏快，病人喘且頸靜脈怒張，顯示循環過量、心臟前負荷過重，護理首要是立即減少繼續進入的液體量，故調慢點滴流速（而非完全移除，以保留靜脈通路備用給藥）為最優先，選D。C直接移除管路會失去給藥途徑且非必要。B半坐臥可減少靜脈回流、緩解呼吸，屬後續措施。A通知醫師雖重要，但應在第一線減慢流速的處置之後。故D最優先。","循環過量（fluid overload）徵象包括呼吸喘、頸靜脈怒張、肺囉音、血壓上升、體重增加。機轉為點滴輸入速度超過心臟輸出負荷，靜水壓升高致肺水腫。處置順序常記為：減慢點滴→半坐臥→給氧→通知醫師→必要時給利尿劑。保留靜脈通路是為後續給藥所需。",[25,28,31,33],{"term":26,"count":27},"循環負荷過量",4,{"term":29,"count":30},"前負荷",2,{"term":32,"count":11},"靜脈輸液流速",{"term":34,"count":11},"靜脈通路維持",[36,40,44,48,53,59],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-109-1-fundamental-nursing-054","管灌飲食（NG diet tube feeding）出現腹瀉合併症後，下列措施何者最適當？",54,{"webId":41,"stem":42,"number":43,"year":10,"session":30},"nurse-109-2-fundamental-nursing-070","依據 Marquis 和 Huston（2011）創造激勵氛圍的策略，下列何者錯誤？",70,{"webId":45,"stem":46,"number":27,"year":47,"session":30},"nurse-110-2-fundamental-nursing-004","有關執行存留導尿的技術，下列敘述何者錯誤？",110,{"webId":49,"stem":50,"number":51,"year":52,"session":30},"nurse-111-2-fundamental-nursing-042","王小姐平時血壓為 110～120\u002F76～80 mmHg。則以錶式血壓計測量時，應充氣至下列何壓力值為佳？",42,111,{"webId":54,"stem":55,"number":56,"year":57,"session":58},"nurse-112-3-fundamental-nursing-006","下列何者屬於護理過程「執行期（implementation）」的工作項目？",6,112,3,{"webId":60,"stem":61,"number":62,"year":63,"session":58},"nurse-113-3-fundamental-nursing-050","同時考慮「工作結構」、「領導者與成員關係」、「職位權力」的關係所發展出的領導行為，屬於下列何種領導理論？",50,113,"2026-09-04",1788510712096]