[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-1-fundamental-nursing-029":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-029","nurse-111-1-fundamental-nursing-029",111,1,29,"吳老先生住院多日未解便，醫囑給予意福灌腸液（EVAC enema）行小量灌腸，下列敘述何者正確？",{"A":15,"B":16,"C":17,"D":18},"灌腸時病人採右側臥，並請其哈氣放輕鬆","灌腸器頂端與肛管之接合處，需以凡士林潤滑","灌腸器頂端軟管塞入肛門之深度為 7.5～10 cm","灌腸中，病人出現痙攣腹痛，請其忍耐直到溶液灌完為止","C",null,[],"本題考點為小量灌腸(意福灌腸)的正確操作。成人灌腸時肛管插入直腸的深度為 7.5～10 公分(約 3～4 吋),過淺溶液易漏出、過深會傷及腸黏膜,故選 C。A 錯在灌腸病人應採左側臥(Sim's 姿),因乙狀結腸位於左側,左側臥順著腸道解剖走向利於溶液灌入,而非右側臥。B 錯在潤滑的部位是肛管前端要插入肛門的部分,以水溶性潤滑劑(非凡士林等油性,油會殘留且不易吸收),而非潤滑接合處。D 錯在灌腸中出現痙攣腹痛應暫停或放慢、降低灌腸筒高度讓病人深呼吸,不可強令忍耐灌完以免腸黏膜受損或迷走神經反應。","灌腸解剖與生理:左側臥使結腸(降結腸、乙狀結腸)處於較低位,溶液靠重力順向流入。肛管插入深度成人 7.5～10 cm、兒童 5～7.5 cm、嬰兒 2.5～3.75 cm。灌腸筒高度一般離肛門約 30～45 cm,高度愈高壓力愈大流速愈快,腹痛時降低高度可減緩痙攣。潤滑劑用水溶性(如 KY gel),避免油性殘留影響黏膜。灌腸中痙攣多因流速過快或溶液過冷刺激腸壁,處置為暫停、放慢、安撫哈氣。",[25,28,30,32],{"term":26,"count":27},"肛管插入深度",2,{"term":29,"count":27},"左側臥",{"term":31,"count":11},"小量灌腸",{"term":33,"count":11},"灌腸痙攣處置",[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-111-1-fundamental-nursing-030","放置存留導尿管的病人需收集尿液檢體進行細菌培養（urine culture），收集方式之敘述下列何者正確？",30,{"webId":40,"stem":41,"number":42,"year":10,"session":27},"nurse-111-2-fundamental-nursing-046","張先生長期仰臥在床上，若未採取預防措施，其髖關節最容易發生何種變化？",46,{"webId":44,"stem":45,"number":46,"year":47,"session":11},"nurse-112-1-fundamental-nursing-060","有關願景內涵的敘述，下列何者最適宜？",60,112,{"webId":49,"stem":50,"number":51,"year":52,"session":11},"nurse-113-1-fundamental-nursing-048","林護理師於病房工作1.5年，對病人整體性照護在指導下可完成，剛晉升為N1層級。護理長對於林護理師的領導，適合採用赫爾賽（Hersey） 與布朗查德（Blanchard）之情境領導理論（situational leadership theory）中的何種領導型態？",48,113,{"webId":54,"stem":55,"number":27,"year":56,"session":57},"nurse-114-3-fundamental-nursing-002","病人承受壓力時的生理反應，下列敘述何者最不適當？",114,3,{"webId":59,"stem":60,"number":42,"year":61,"session":11},"nurse-106-1-fundamental-nursing-046","病人長時間採半坐臥姿勢，身體受壓處不包括下列那一部位？",106,"2026-09-04",1788510733685]