[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-113-2-fundamental-nursing-022":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-022","nurse-113-2-fundamental-nursing-022",113,2,22,"記錄導尿管留置病人的輸出入量時，發現 3 小時中尿袋內的尿量為零，應先執行下列何項處置？",{"A":15,"B":16,"C":17,"D":18},"準備進行大量輸液","準備重新放置導尿管","通知醫生進行緊急處理","檢查導尿系統的通暢性","D",null,[],"本題考點在於留置導尿管無尿（尿袋 3 小時零尿量）時的護理處置優先順序。依據護理處置原則,應先排除最常見且可立即處理的機械性因素——檢查導尿系統是否通暢（有無扭曲、壓迫、阻塞或尿管位置不當），故 D 為首要處置,選 D。A 大量輸液、B 重新置放導尿管、C 通知醫師緊急處理,都應在確認並排除導管阻塞這類簡易可逆原因之後才考慮,不宜跳過基本檢查就採取侵入或緊急措施。","面對留置導尿無尿,護理判斷順序:先查「導管系統」(是否扭曲、受壓、被身體壓住、集尿袋位置過高、管路阻塞)，此為最常見且可立即矯正者;排除後再評估是否真為尿量減少（少尿\u002F無尿），才通報醫師處理腎前、腎因或腎後性問題。護理原則:先做非侵入、可逆、成本低的評估,再升級處置。這也呼應「評估先於處置」的護理過程精神。",[25,27,30,32],{"term":26,"count":11},"評估先於處置",{"term":28,"count":29},"留置導尿無尿",1,{"term":31,"count":29},"檢查導管通暢性",{"term":33,"count":29},"護理處置優先順序",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-113-2-fundamental-nursing-023","有關移動病人並協助擺位，下列敘述何者正確？",23,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-114-1-fundamental-nursing-019","有關臥姿與其目的之敘述，下列何者正確？",19,114,{"webId":45,"stem":46,"number":47,"year":43,"session":48},"nurse-114-3-fundamental-nursing-013","有關用熱的生理效應，下列敘述何者最適當？",13,3,{"webId":50,"stem":51,"number":52,"year":53,"session":29},"nurse-106-1-fundamental-nursing-061","某護理師負責照護 6 位病人，上午 9 點時測量生理指標及給藥。甲病人因疼痛要求止痛劑；乙病人血壓高，要求降壓劑；丙病人主訴胸部悶痛臉色發白，醫囑要立即做 EKG。以上情境中那一項是緊急且重要的工作？",61,106,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-107-2-fundamental-nursing-025","有關全身和局部用冷熱療法的敘述，下列何者正確？①冷熱應用面積越大，效果越好，耐受力也越佳 ②全身用熱則會使血管擴張血循改變，腦血流減少導致頭暈 ③全身用熱時間如果過長，就會產生交感反應，而讓血管擴張更加厲害 ④全身用冷熱的危險性較局部使用冷熱療法為大",25,107,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-108-2-fundamental-nursing-059","規劃是建構及發展一套解決問題或達成目標行動方案之過程，下列何者為其核心觀念？",59,108,"2026-09-04",1788510754561]