[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-2-fundamental-nursing-050":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":63},"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-110-2-基本護理學與護理行政-050","nurse-110-2-fundamental-nursing-050",110,2,50,"醫囑每 2 小時間歇管灌食的病人，已於 8：00 am 灌食 250 mL 後，於 10：00 am 管灌前反抽鼻胃管有 150 mL 之未消化液，下列處置何者最適當？",{"A":15,"B":16,"C":17,"D":18},"將病人採右側臥以促進胃排空，一小後再給予灌食","評估腸蠕動音，並給予胃部按摩","減少灌食量，此次給予灌食 100 mL","暫停鼻胃灌食，並與醫師討論","D",null,[],"本題考點在管灌前反抽胃內殘餘量(gastric residual)的判讀與處置。8:00 灌食 250 mL，10:00 反抽出 150 mL 未消化液，殘餘量偏高(達前次灌食量過半，超過一般 100–150 mL 警戒值)，顯示胃排空延遲、有吸入風險，最適當處置為暫停灌食並與醫師討論，選 D。採右側臥並延後一小時(A)、按摩胃部(B)、逕自減量灌食(C)都在殘餘量過高、未釐清原因下持續灌食，增加吸入性肺炎風險，故非最適當。","高胃殘餘量提示胃排空障礙，常見於術後腸麻痺、藥物(鴉片類)、電解質異常等，持續灌食恐致嘔吐與吸入性肺炎。一般作法：殘餘量過高時暫停、抬高床頭 30–45 度、評估腸蠕動音並回報醫師；反抽液通常回輸以免流失電解質。記憶：殘餘高就暫停、抬床頭、聽腸音、報醫師。",[25,28,31,33],{"term":26,"count":27},"吸入性肺炎",3,{"term":29,"count":30},"胃殘餘量",1,{"term":32,"count":30},"管灌食",{"term":34,"count":30},"胃排空延遲",[36,40,45,49,53,58],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-110-2-fundamental-nursing-051","有關入院病人護理措施，下列何者適當？ ①需在接病人的當班內完成所有的護理評估等病歷內容 ②自我介紹及觀察病人是最先的護理活動 ③需建立身高、體重及生命徵象的資料 ④護理人員應主動保管病人貴重物品，以免遺失",51,{"webId":41,"stem":42,"number":43,"year":44,"session":30},"nurse-111-1-fundamental-nursing-067","利用工作分析，重新定義工作或職務，確認出新的工作職責和職權，屬於下列何種工作設計？",67,111,{"webId":46,"stem":47,"number":30,"year":48,"session":30},"nurse-112-1-fundamental-nursing-001","王先生，闌尾炎痊癒即將出院，但看起來心情欠佳。依羅氏適應模式（Roy’s adaptation model）生理、心理與社會的整體評估，下列敘述何者正確？",112,{"webId":50,"stem":51,"number":52,"year":48,"session":27},"nurse-112-3-fundamental-nursing-039","某病房護理師之臨床經驗皆為 3 年以上，無新進人員，護理人力配置亦符合醫院評鑑之護病比，在此情況下，最適合採用下列何種護理照護模式？",39,{"webId":54,"stem":55,"number":56,"year":57,"session":30},"nurse-114-1-fundamental-nursing-043","有關集權式組織的優點，下列敘述何者正確？",43,114,{"webId":59,"stem":60,"number":61,"year":62,"session":11},"nurse-115-2-fundamental-nursing-037","新進護理人員訓練時，院長提及該院在未來五年要成為以社區為導向的優質區域醫院，此敘述最符合下列何者？",37,115,"2026-09-04",1788510728495]