[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-1-fundamental-nursing-024":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":62},"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-111-1-基本護理學與護理行政-024","nurse-111-1-fundamental-nursing-024",111,1,24,"李先生體重 60 公斤，輸血醫囑「Blood transfusion PRBC（packed RBC）2 units」，輸血開始 15 分鐘後，出現頭痛、寒顫、發燒、呼吸困難、低血壓等症狀，此時護理師在通知醫師之前，最優先的處理為何？",{"A":15,"B":16,"C":17,"D":18},"立即停止輸血，以生理鹽水維持靜脈通暢","調慢滴速，測量生命徵象","抽血做血液培養","調高病人床頭，給予氧氣","A",null,[],"本題考點為輸血反應的緊急處置優先順序。輸血開始 15 分鐘內出現寒顫、發燒、呼吸困難、低血壓,屬急性溶血性或嚴重過敏性輸血反應,持續輸入的血品是致命來源,故最優先須立即停止輸血,並改用生理鹽水維持靜脈通暢(避免管路阻塞、保留給藥途徑),選 A。B 錯在只調慢滴速仍讓不相容血液持續進入體內,無法移除致命源。C 抽血做血液培養是後續釐清原因的檢查,不是第一步。D 給氧與擺位屬支持性處置,在停止輸血之後才進行。輸血只能用生理鹽水沖洗管路,不可用含葡萄糖或含鈣溶液以免溶血或凝集。","急性溶血反應的病生理是 ABO 不相容抗體與供血紅血球抗原結合、活化補體造成血管內溶血,可引發 DIC、急性腎衰竭與休克,死亡風險與輸入量成正比,因此「停輸」是止血止損的關鍵。記憶順序:停輸血→換生理鹽水維持管路→評估生命徵象→通知醫師→留存血袋與抽血送檢(驗溶血、重新交叉配對、血液培養)。生理鹽水為唯一相容溶液,因葡萄糖溶液低張會使紅血球溶解,林格氏液含鈣會促進凝血。",[25,28,30,32],{"term":26,"count":27},"輸血相容溶液",2,{"term":29,"count":11},"急性溶血性輸血反應",{"term":31,"count":11},"停止輸血",{"term":33,"count":11},"生理鹽水維持靜脈通暢",[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-111-1-fundamental-nursing-025","有關用熱治療所產生全身性反應的敘述，下列何者正確？①血壓上升 ②頭暈 ③呼吸變慢 ④脈搏加速",25,{"webId":40,"stem":41,"number":42,"year":10,"session":27},"nurse-111-2-fundamental-nursing-041","關於影響血壓的因素，下列敘述何者正確？",41,{"webId":44,"stem":45,"number":46,"year":47,"session":11},"nurse-112-1-fundamental-nursing-055","吳爺爺，肺癌合併腦、骨頭多處轉移，骨轉移疼痛目前有 Morphine 10 mg S.C. q4h+p.r.n.使用，臨終階段出現譫妄、躁動不安之情形，案妻詢問醫療人員：「看他這樣很捨不得，可以用點藥讓他休息一下嗎？」醫療人員如何回應較為適宜？",55,112,{"webId":49,"stem":50,"number":51,"year":52,"session":11},"nurse-113-1-fundamental-nursing-043","下列何種組織結構最適合規模小且複雜性低的護理之家？",43,113,{"webId":54,"stem":55,"number":56,"year":57,"session":27},"nurse-114-2-fundamental-nursing-047","傑克斯（Jaques, 1961）指出，員工的工作滿意度取決於能力（capacity, C）、生產力（work productivity, W）及報酬（pay level, P）三者之間的關係，下列何種狀況會讓員工有被剝削懲罰感？",47,114,{"webId":59,"stem":60,"number":42,"year":61,"session":11},"nurse-106-1-fundamental-nursing-041","照護 1 歲 9 個月的兒童時，測量生命徵象的順序，下列何者正確？",106,"2026-09-04",1788510733642]