[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-112-2-fundamental-nursing-024":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-112-2-基本護理學與護理行政-024","nurse-112-2-fundamental-nursing-024",112,2,24,"張女士因肺癌，術後醫囑開立 FFP 2U St.，在輸注過程中，出現頭暈、呼吸困難、血壓下降，下列之立即處置何者最適當？",{"A":15,"B":16,"C":17,"D":18},"此現象為正常的反應，持續輸血","調慢輸血滴速，立刻跑回護理站通知護理長","調慢輸血滴速，馬上給予利尿劑及氧氣","立刻停止輸血，並使用 0.9% N\u002FS 維持靜脈輸液管路通暢","D",null,[],"本題考點是輸血反應中的循環負荷過量與過敏／溶血反應之緊急處置原則。依輸血安全準則,一旦出現頭暈、呼吸困難、血壓下降等異常徵象,首要動作是「立刻停止輸血」以中斷可能的致病原,並更換為 0.9% 生理食鹽水維持靜脈管路通暢,以便後續給藥與保留檢體,故選 D。A 錯,這些症狀絕非正常反應,持續輸血會加重危害。B 錯,調慢滴速並未中斷致病血品,且「跑回護理站」延誤處置。C 錯,先給利尿劑及氧氣而未停止輸血,順序顛倒,應先停血再處理。生理食鹽水與血品不會產生凝集反應,是唯一可與輸血共用的溶液。","輸血反應處置的鐵律口訣為「停血、換鹽水、保管路、通報並留檢體」。停血是為了中斷抗原抗體反應的來源;改接 0.9% N\u002FS 是因為葡萄糖溶液會使紅血球凝集溶血、含鈣溶液(如 Lactated Ringer's)會與血品抗凝劑 citrate 螯合而促凝,唯有等張生理食鹽水安全。保留剩餘血袋與病人血液檢體供血庫比對,是釐清溶血反應的關鍵。此題情境也可對比循環負荷過量(TACO),其處置除停血外會採半坐臥、給氧與利尿,但前提同樣是先停止輸血。",[25,28,31,33],{"term":26,"count":27},"循環負荷過量",4,{"term":29,"count":30},"輸血反應緊急處置",1,{"term":32,"count":30},"停止輸血原則",{"term":34,"count":30},"0.9% 生理食鹽水維持管路",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-112-2-fundamental-nursing-025","有關能量轉移方式的原理和運用之敘述，下列何者正確？",25,{"webId":41,"stem":42,"number":43,"year":10,"session":44},"nurse-112-3-fundamental-nursing-041","有關排班的類型，下列敘述何者正確？",41,3,{"webId":46,"stem":47,"number":48,"year":49,"session":11},"nurse-113-2-fundamental-nursing-035","安寧病房末期臨終病人已簽署不施行心肺復甦術同意書，案妻看到病人呼吸微弱且意識不清，緊張地要求對病人進行急救，您為其主護護理師，下列回應何者最適當？",35,113,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-114-3-fundamental-nursing-033","腦腫瘤成年病人住院治療，護理師評估肌力時，發現病人左側手腳肌肉輕微收縮，但關節無法活動；最適合病人左側肢體的運動型態，下列何者正確？",33,114,{"webId":56,"stem":57,"number":58,"year":59,"session":11},"nurse-106-2-fundamental-nursing-007","林先生在修理門窗時不慎由二樓摔下來，經家人送到醫院急診時，臉色蒼白、閉眼皺眉、呼吸急促並主訴頭暈。護理師測得其血壓為 142\u002F96 mmHg、心跳 102 次\u002F分。下列何者正確？",7,106,{"webId":61,"stem":62,"number":43,"year":63,"session":11},"nurse-107-2-fundamental-nursing-041","李太太，80 歲，身高 160 公分，體重 82 公斤，有糖尿病二十多年，以降血糖藥物控制；近日因左腳疼痛，大拇趾已有壞疽發黑情形，無法下床走路，整天臥床休息，有腹瀉情形，故予以包尿布；今早護理師發現李太太的薦骨處有一處 1 × 2 cm 2 的皮膚呈發紅、腫脹和起水泡情形。下列何者不是造成李太太產生壓瘡的危險因子？",107,"2026-09-04",1788510746801]