[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-114-3-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":27},"nurse-114-3-基本護理學與護理行政-016","nurse-114-3-fundamental-nursing-016",114,3,16,"當病人接受靜脈輸注而發生血栓靜脈炎時，下列處理何者最適當？",{"A":15,"B":16,"C":17,"D":18},"立即移除原注射針","調慢輸液滴注的速度","給予濕冷敷及按摩","抬高注射部位","A",null,[],"本題考點在於靜脈輸注併發血栓靜脈炎（thrombophlebitis）的第一線處置。依靜脈炎處理原則，一旦局部出現紅、腫、熱、痛沿靜脈走向的發炎，代表該血管已受化學或機械刺激而受損，首要動作是停止輸注並移除原注射針，另換部位重打，再輔以熱敷促進發炎吸收，故選 A。B 調慢滴速無法解決已成形的靜脈壁發炎與血栓，刺激仍持續，非最適當。C 錯在兩處：靜脈炎應熱敷而非冷敷，且絕不可按摩該部位，以免血栓鬆脫造成栓塞。D 抬高患肢雖可減輕靜脈鬱血與腫脹，屬輔助措施，仍無法取代移除針頭這個根本處置，故非最佳解。","血栓靜脈炎的病生理是靜脈內膜受損（高滲透壓藥物、留置過久、導管刮傷）引發血栓形成與發炎級聯反應。記憶要訣：靜脈炎「先拔針、再熱敷、勿按摩」。熱敷使局部血管擴張、加速滲出物與發炎介質吸收；按摩則是大忌，等同把栓子往中央推。臨床上以 VIP score（Visual Infusion Phlebitis）分級決定是否移除導管，出現條索狀硬結即屬需拔除等級。可連結延伸：靜脈炎分為化學性、機械性、細菌性三類，預防重點在選對血管、稀釋刺激性藥物與定期更換部位。",[25,28,30,32],{"term":26,"count":27},"血栓靜脈炎",1,{"term":29,"count":27},"靜脈炎處置原則",{"term":31,"count":27},"熱敷",{"term":33,"count":27},"血栓脫落與栓塞風險",[35,39,45,50,55,60],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-114-3-fundamental-nursing-017","使用冷、熱療法產生的生理反應，所達成的相同效果，下列敘述何者最適當？①減緩炎症反應 ②減緩疼痛 ③減緩關節僵硬 ④減緩充血與腫脹",17,{"webId":40,"stem":41,"number":42,"year":43,"session":44},"nurse-115-2-fundamental-nursing-013","扁桃腺手術後，醫囑開立冰領使用，有關冷應用與照護的敘述，下列何者正確？",13,115,2,{"webId":46,"stem":47,"number":48,"year":49,"session":27},"nurse-106-1-fundamental-nursing-057","醫院為提升護理品質，要培養 5 位 N2 護理師完成護理專業能力進階至 N3。以上工作目標敘述，下列 5W 中缺少什麼？",57,106,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-107-2-fundamental-nursing-015","以下醫囑：N\u002FS 500 c.c. + KCL 15 mEq IVD stat.，如果 KCL 1 amp.容量為 20 c.c. 內含有 KCL 40 mEq，加入的 KCL 有多少 c.c.？",15,107,{"webId":56,"stem":57,"number":58,"year":59,"session":44},"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,{"webId":61,"stem":62,"number":42,"year":63,"session":27},"nurse-110-1-fundamental-nursing-013","有關「p.r.n.」醫囑的敘述，下列何者錯誤？①是一種臨時醫囑 ②開立醫囑時，醫師會指定間隔時間多久一次 ③中文解釋為「如有需要僅給予一次」 ④執行後須記錄 ⑤此醫囑有效時間為 12 小時",110,"2026-09-04",1788510761544]