[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-114-2-medical-surgical-025":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":65},"內外科護理學","medical-surgical",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-114-2-內外科護理學-025","nurse-114-2-medical-surgical-025",114,2,25,"王先生接受輸血治療過程中發生乾咳、血壓上升、嚴重呼吸困難等情形，下列何者為其最有可能發生的輸血不良反應？",{"A":14,"B":15,"C":16,"D":17},"循環過度負荷","過敏反應","熱原反應","溶血反應","A",null,[],"本題考點在於輸血不良反應的鑑別診斷。依臨床表徵,乾咳、血壓上升、嚴重呼吸困難是循環容積過度負荷(TACO)的典型表現,因輸血速度過快或量過多使血管內容積驟增、引發肺水腫,故選 A 循環過度負荷。B 過敏反應以蕁麻疹、搔癢、甚至過敏性休克(血壓下降)為主。C 熱原反應(發熱性非溶血反應)以發燒、寒顫為主。D 溶血反應以發燒、腰背痛、血紅素尿與血壓下降為特徵,皆與本題血壓「上升」加肺充血不符,故排除。","鑑別關鍵在「血壓方向」與「呼吸型態」:TACO=血壓升、頸靜脈怒張、肺水腫(容積過載);過敏與溶血多見血壓降。TACO 好發於心腎功能不佳與老人,處置為停\u002F減慢輸血、採坐姿、給利尿劑。對比 TRALI(輸血相關急性肺損傷)則血壓常降、與抗體有關,兩者都表現呼吸窘迫但機轉不同。",[24,27,30,32],{"term":25,"count":26},"肺水腫",9,{"term":28,"count":29},"輸血反應",3,{"term":31,"count":10},"循環過度負荷 TACO",{"term":33,"count":10},"輸血反應鑑別",[35,39,45,50,55,60],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-114-2-medical-surgical-026","承上題，有關王先生的護理與處置，下列何者正確？",26,{"webId":40,"stem":41,"number":42,"year":43,"session":44},"nurse-115-1-medical-surgical-022","王老太太背部骨骼疼痛就醫，醫生懷疑是多發性骨髓瘤，請依序回答下列3題。下列何者為確定診斷的主要標準？",22,115,1,{"webId":46,"stem":47,"number":48,"year":49,"session":44},"nurse-106-1-medical-surgical-016","有關接受活體肝臟切片檢查病人之護理，下列何者錯誤？",16,106,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-107-1-medical-surgical-054","70 歲的劉老先生，一個月前不小心頭部撞到門框，近一星期家人發現劉老先生行為怪異，送醫檢查後診斷為慢性硬膜下出血，下列敘述何者錯誤？",54,107,{"webId":56,"stem":57,"number":58,"year":59,"session":10},"nurse-108-2-medical-surgical-018","有關中耳手術後病人護理措施及指導之敘述，下列何者錯誤？",18,108,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-109-2-medical-surgical-052","有關吸入性肺炎之臨床症狀，下列何者須立即處理？",52,109,"2026-09-04",1788510759683]