[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-110-2-fundamental-nursing-035":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"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-110-2-基本護理學與護理行政-035","nurse-110-2-fundamental-nursing-035",110,2,35,"病人右手臂正在進行靜脈輸液，護理人員發現其點滴流速不順暢、沒有回血、注射部位水腫且冰冷，下列處置何者最適當？",{"A":15,"B":16,"C":17,"D":18},"調整右手臂的位置並調高點滴架","右手臂注射部位進行熱敷","調整血管中靜脈留置針的長度","停止輸注並移除靜脈留置針","D",null,[],"本題考點在靜脈注射滲漏(infiltration)的辨識與處置。點滴流速不順、回抽無回血、注射部位水腫且冰冷，屬非發炎性液體滲入皮下組織的浸潤徵象；局部冰冷代表非藥液外滲併發炎(靜脈炎會紅熱)。考點在於一旦確認滲漏，應停止輸注並移除留置針以免組織持續腫脹受損，選 D。調整手臂位置與點滴架高度(A)無法解決針頭已滑出血管的問題；熱敷(B)是移除後視情況的後續處理，非首要；靜脈留置針長度無法在血管內任意調整(C)為不合理操作，故均不當。","浸潤(infiltration)與外滲(extravasation)區別在藥液是否具腐蝕或發泡性；外滲(如化療藥)可致組織壞死更需緊急處理。徵象：腫脹、皮膚繃緊發亮、冰冷、點滴變慢、回抽無回血。移除後可抬高患肢並依醫囑冷或熱敷。記憶四要點：腫、冷、慢、無回血即拔針。相對地靜脈炎為紅、腫、熱、痛沿血管走向。",[25,27,30,32],{"term":26,"count":11},"靜脈滲漏",{"term":28,"count":29},"infiltration",1,{"term":31,"count":29},"留置針移除",{"term":33,"count":29},"靜脈炎鑑別",[35,39,44,48,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-110-2-fundamental-nursing-036","靜脈輸注部位的選擇原則，下列何者正確？",36,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-111-1-fundamental-nursing-052","護理師協助收集常規尿液檢查，發現尿液呈現螢光黃色，下列何者為最可能之原因？",52,111,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-111-2-fundamental-nursing-066","有關人事管理及人力資源管理的敘述，下列何者正確？",66,{"webId":49,"stem":50,"number":51,"year":52,"session":53},"nurse-112-3-fundamental-nursing-024","有關脈搏速率的敘述，下列何者錯誤？",24,112,3,{"webId":55,"stem":56,"number":57,"year":58,"session":29},"nurse-114-1-fundamental-nursing-028","病人因車禍接受右側膝關節上方的截肢手術，下列何者最適用於術後殘肢包紮？",28,114,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-115-2-fundamental-nursing-022","下列何者不是足部按摩的禁忌症？",22,115,"2026-09-04",1788510728338]