[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-110-1-fundamental-nursing-056":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":33,"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":11},"nurse-110-1-基本護理學與護理行政-056","nurse-110-1-fundamental-nursing-056",110,1,56,"趙先生 68 歲，意識清楚，診斷肝硬化合併食道靜脈曲張，血小板：22,000\u002FμL，痰乾且量少，因病人發燒寒顫，醫師開立收集痰液培養（sputum culture）之醫囑，護理人員應如何執行最為適當？",{"A":15,"B":16,"C":17,"D":18},"以抽痰方式取得痰液，抽吸壓力維持於 150～170mmHg","鼓勵病人深呼吸後，立刻用力咳出痰液","鼓勵先以漱口劑清潔口腔，避免標本污染","先給予 0.45% NaCl 噴霧吸入，稀釋痰液後配合呼氣咳痰","D",null,[],"本題考點在合併食道靜脈曲張與血小板過低（22,000\u002FμL）病人採痰的安全考量。依出血風險評估，此病人凝血功能差、食道靜脈易破裂，應避免抽痰負壓損傷及用力咳嗽引發的腹壓上升。選項 D 以 0.45% NaCl 噴霧吸入稀釋濃稠痰液、再配合呼氣輕咳，最為溫和安全，故為正解。A 抽痰負壓 150～170 mmHg 易造成黏膜損傷出血，不宜。B「立刻用力咳出」會驟增腹內壓，恐誘發食道靜脈曲張破裂出血。C 漱口雖可減污染，但無法解決痰乾量少的取樣困難，非最適當處置。","關鍵在「血小板低＋食道靜脈曲張」＝高出血風險。任何增加腹壓、胸腔壓或負壓抽吸的動作都可能誘發致命性上消化道出血，故採「霧化稀釋＋輕柔咳痰」的低風險策略取檢。",[25,27,29,31],{"term":26,"count":11},"食道靜脈曲張",{"term":28,"count":11},"血小板減少",{"term":30,"count":11},"出血風險",{"term":32,"count":11},"痰液採檢",[34,38,43,48,53,59],{"webId":35,"stem":36,"number":37,"year":10,"session":11},"nurse-110-1-fundamental-nursing-057","有關目標管理的敘述，下列何者錯誤？",57,{"webId":39,"stem":40,"number":41,"year":10,"session":42},"nurse-110-2-fundamental-nursing-073","有關技術混合照護模式，下列敘述何者最適當？",73,2,{"webId":44,"stem":45,"number":46,"year":47,"session":42},"nurse-111-2-fundamental-nursing-007","當某病房出現火災時，以 R.A.C.E.原則處理，有關其口訣與意義的敘述，下列何者錯誤？",7,111,{"webId":49,"stem":50,"number":51,"year":52,"session":42},"nurse-112-2-fundamental-nursing-045","病患接受 650 mOsm\u002FkgH 2 O 管灌配方，以 60c.c.\u002F小時連續灌食法提供營養後，開始出現腹瀉，下列何者為改善腹瀉的合宜措施？",45,112,{"webId":54,"stem":55,"number":56,"year":57,"session":58},"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？",19,113,3,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-115-1-fundamental-nursing-013","醫囑：tacrolimus 1 mg\u002Fcap 1 cap. QD P.O. 為持續性藥效膠囊，其正確的服用方式為何？",13,115,"2026-09-04",1788510720497]