[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-112-1-fundamental-nursing-045":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"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":27},"nurse-112-1-基本護理學與護理行政-045","nurse-112-1-fundamental-nursing-045",112,1,45,"護理師為病人執行鼻胃管灌食，下列措施何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"食物剛從冰箱拿出應隔水加熱，溫度以接近體溫為宜","灌食前，反抽出現 150 mL 咖啡色未消化食物，將其打回，暫不餵食","每次灌食量不超過 500 mL，灌食時間約 20 分鐘","灌食後抬高床頭約 30～60 分鐘，2 小時內不可抽痰","B",null,[],"本題考點在於鼻胃管灌食的安全措施，須找出錯誤者。反抽（residual）目的在評估胃排空與腸胃出血，若抽出 150 mL「咖啡色未消化」內容物，咖啡色可能代表上消化道出血或食物滯留，應保留檢視並通報，不可貿然「打回」灌注，故 B 措施錯誤，正解 B。A 冰箱取出的食物隔水加熱至接近體溫，避免過冷刺激腸胃，正確；C 每次灌食量與速度控制、時間約 20 分鐘以防脹氣嘔吐，正確；D 灌食後抬高床頭並暫不抽痰以降低吸入性肺炎風險，正確。唯咖啡色反抽物打回的處置違反安全原則。","反抽物顏色判讀：咖啡色／紅色警示消化道出血須通報。大量反抽（一般 >100–150 mL）代表胃滯留，宜暫停並評估。灌食後抬高床頭 30–60 分鐘、避免立即抽痰，皆為預防吸入的機轉。記法「咖啡色別打回，先留樣、先通報」。",[25,28,31,33],{"term":26,"count":27},"鼻胃管灌食",6,{"term":29,"count":30},"吸入性肺炎預防",4,{"term":32,"count":11},"胃內容物反抽",{"term":34,"count":11},"上消化道出血警示",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-112-1-fundamental-nursing-046","下列疾病與異常呼吸的敘述何者錯誤？",46,{"webId":41,"stem":42,"number":43,"year":10,"session":44},"nurse-112-2-fundamental-nursing-062","有關目標管理中的目標設定，下列何者為具體可測量？",62,2,{"webId":46,"stem":47,"number":48,"year":49,"session":11},"nurse-113-1-fundamental-nursing-026","調節呼吸的重要化學物質，不包括下列那一項？",26,113,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-114-2-fundamental-nursing-024","有關影響體溫的因素，下列何者錯誤？",24,114,{"webId":56,"stem":57,"number":58,"year":59,"session":11},"nurse-106-1-fundamental-nursing-028","醫囑「500 mL Half Saline 以一般輸液套管靜脈滴注（每毫升 20 gtt），且須在 4 小時內輸注完畢」，下列何者為最適當的滴注速度？",28,106,{"webId":61,"stem":62,"number":43,"year":63,"session":11},"nurse-107-1-fundamental-nursing-062","護理師每 6 年須接受一定時數的繼續教育才可以辦理執照更新，這是屬於下列何種護理專業形象建立之作為？",107,"2026-09-04",1788510741333]