[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-113-2-fundamental-nursing-016":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"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":11},"nurse-113-2-基本護理學與護理行政-016","nurse-113-2-fundamental-nursing-016",113,2,16,"輸血時發生咳嗽、心搏過速、高血壓及呼吸困難症狀，最有可能發生下列何種反應？",{"A":15,"B":16,"C":17,"D":18},"溶血反應","循環負荷過量","過敏性反應","熱原反應","B",null,[],"本題考點在於輸血反應的類型鑑別。病人出現咳嗽、心搏過速、高血壓與呼吸困難,依據輸血反應的臨床表現,這組症狀典型指向循環負荷過量（transfusion associated circulatory overload, TACO）——輸血速度過快或量過多使血循量驟增、心臟負荷過重,引發肺充血與呼吸困難,故選 B。A 溶血反應以發燒、寒顫、腰背痛、血尿為主;C 過敏性反應以蕁麻疹、搔癢、支氣管痙攣甚至休克表現,血壓多下降;D 熱原反應以發燒寒顫為主。唯循環負荷過量會呈現血壓上升合併肺水腫症狀。","循環負荷過量（TACO）關鍵在「血壓升高＋肺充血」,好發於心腎功能不佳的老人或幼兒。處置方向為減慢或停止輸血、採坐姿、給氧、依醫囑用利尿劑。鑑別重點:溶血與過敏、熱原反應血壓多下降,唯 TACO 因血容量增加使血壓上升、頸靜脈怒張、端坐呼吸。記憶口訣:「輸太快太多、血壓升、肺積水」即想到循環負荷過量。",[25,27,30,32],{"term":26,"count":11},"輸血反應",{"term":28,"count":29},"循環負荷過量TACO",1,{"term":31,"count":29},"肺充血",{"term":33,"count":29},"血壓上升鑑別",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-113-2-fundamental-nursing-017","王先生因服用毛地黃而出現脈搏短絀情況，下列敘述何者錯誤？",17,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-114-1-fundamental-nursing-013","醫囑開立oxacillin 1 gm Q6H I.V. drip，oxacillin藥瓶標示為250 mg\u002Fvial，每次給藥時應抽幾瓶（vial）？",13,114,{"webId":45,"stem":46,"number":47,"year":43,"session":48},"nurse-114-3-fundamental-nursing-007","與已建立信任關係的病人會談時，下列會談距離何者最適當？",7,3,{"webId":50,"stem":51,"number":52,"year":53,"session":29},"nurse-106-1-fundamental-nursing-055","診斷 COPD 末期之瀕死病人，醫囑每日執行動脈血液氣體分析，下列護理師的回應何者最適切？",55,106,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-107-2-fundamental-nursing-019","郭小妹，6 歲，體重 18 公斤，醫囑「vancomycin 240mg IVF q6h」。vancomycin 的藥品說明書載明：「孩童的安全用量為 40mg\u002Fkg\u002Fday，須分次給藥」。針對此醫囑的執行，下列敘述何者最適當？",19,107,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-108-2-fundamental-nursing-053","張小姐住院期間需留取常規尿液檢體，下列敘述何者正確？①最好是清晨第一次的中段尿 ②檢體收集後，最好於室溫 3 小時內送檢 ③若正值生理期，可用導尿方式取得檢體 ④檢體若 3 小時內無法送檢，應置於冰箱",53,108,"2026-09-04",1788510754507]