[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-111-2-fundamental-nursing-024":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"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":11},"nurse-111-2-基本護理學與護理行政-024","nurse-111-2-fundamental-nursing-024",111,2,24,"有關執行輸血措施的步驟，下列何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"輸血前病人姓名、血型、血液種類及血袋號碼為必核對資料","輸血開始 15 分鐘內速度宜為 20～40 滴／分","除了大量失血有休克傾向者外，一般輸血時不建議加壓輸血","一般輸血完，應立即使用林格氏溶液輸注","D",null,[],"本題考點是輸血流程的安全措施。依輸血後管路沖洗原則,輸血完畢應使用0.9%生理食鹽水沖洗管路,絕不可用含鈣的林格氏溶液(Ringer's),因鈣離子會與血品中的抗凝劑citrate結合促使血液凝集,故D「立即使用林格氏溶液」錯誤,為正解。A正確,輸血前須核對病人姓名、血型、血液種類與血袋號碼等資料。B正確,輸血開始15分鐘內宜慢速20～40滴\u002F分以觀察急性輸血反應。C正確,除大量失血休克傾向者外一般不加壓輸血以免溶血。考點在於辨識與血品相容的沖洗液,牢記僅生理食鹽水可與血液共用管路。","血品保存以citrate為抗凝劑,原理是螯合鈣離子阻斷凝血連鎖。含鈣輸液(如Lactated Ringer's)會提供鈣使凝血啟動,故輸血管路只能用0.9% NS沖洗,葡萄糖液也不可(會使紅血球溶血凝集)。開始15分鐘慢速是黃金觀察期,急性溶血反應多在此時出現(發燒、寒顫、腰痛、血尿)。記憶:輸血只配生理食鹽水,遇鈣遇糖都出事。核對三讀五對加雙人確認是防止溶血性輸血反應的關鍵屏障。",[25,27,30,32],{"term":26,"count":11},"生理食鹽水沖洗",{"term":28,"count":29},"輸血安全核對",1,{"term":31,"count":29},"林格氏液含鈣禁忌",{"term":33,"count":29},"輸血反應觀察",[35,39,44,48,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-111-2-fundamental-nursing-025","冷療可以抑制炎症反應的主要原理，下列何者正確？",25,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-112-1-fundamental-nursing-041","下列那些病人評估脈搏時測量心尖脈較適宜？①服用毛地黃 ②足部手術後 ③7 歲兒童 ④腎衰竭出現四肢水腫",41,112,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-112-2-fundamental-nursing-055","有關臨終病人的護理措施，下列何者適當？",55,{"webId":49,"stem":50,"number":51,"year":52,"session":53},"nurse-113-3-fundamental-nursing-023","有關協助病人維持良好姿勢的原則，下列敘述何者正確？",23,113,3,{"webId":55,"stem":56,"number":57,"year":58,"session":29},"nurse-115-1-fundamental-nursing-027","關於肢體繃帶包紮原則與注意事項，下列何者錯誤？",27,115,{"webId":60,"stem":61,"number":42,"year":62,"session":11},"nurse-106-2-fundamental-nursing-041","身體散熱的主要途徑，下列何者正確？",106,"2026-09-04",1788510737689]