[{"data":1,"prerenderedAt":48},["ShallowReactive",2],{"q-nurse-107-2-fundamental-nursing-021":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":24},"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,"freq":23},"nurse-107-2-基本護理學與護理行政-021","nurse-107-2-fundamental-nursing-021",107,2,21,"小可是一個妊娠週數 32 週的早產兒，目前體重 1.8 kg，有低血糖情形，給與 12.5% glucose water 靜脈輸注中。小可因血紅素過低，依醫囑輸血，輸血後 10 分鐘出現發燒、心搏過速、低血壓、血尿等情形，下列護理措施何者須優先執行？",{"A":15,"B":16,"C":17,"D":18},"保留輸血裝置與採集血液送檢驗","請值班醫師開醫囑給藥","停止輸血，以 0.9% NaCl 維持靜脈通暢","記錄輸出入量代號：2106 頁次：6－3","C",null,[],"本題考點為輸血反應發生時的優先護理措施。個案輸血後 10 分鐘即出現發燒、心搏過速、低血壓、血尿，屬急性輸血反應，依處置原則首要動作是立即停止輸血，並改以 0.9% NaCl(生理食鹽水)維持靜脈通暢，故選 C。A 保留輸血裝置與採血送檢是後續確認反應原因的步驟，須在停血後進行。B 通知醫師開立醫囑固然重要，但不能凌駕先停止致害輸血。D 記錄輸出入量屬常規紀錄，非危急當下的優先順序。",1,[25,29,32,36,40,44],{"webId":26,"stem":27,"number":23,"year":28,"session":23},"nurse-106-1-fundamental-nursing-001","下列何者為預防院內感染最經濟有效的方法？",106,{"webId":30,"stem":31,"number":11,"year":28,"session":23},"nurse-106-1-fundamental-nursing-002","下列那一種健康問題會導致體溫過高？",{"webId":33,"stem":34,"number":35,"year":28,"session":23},"nurse-106-1-fundamental-nursing-003","王先生因腦血管損傷住院中，下列何種灌注溶液不適合王先生使用？",3,{"webId":37,"stem":38,"number":39,"year":28,"session":23},"nurse-106-1-fundamental-nursing-004","醫囑為 Acetaminophen 1 tab q6h p.r.n. if BT≧39℃之含義，下列敘述何者正確？",4,{"webId":41,"stem":42,"number":43,"year":28,"session":23},"nurse-106-1-fundamental-nursing-005","測量 H5N1 流感病毒感染病人生命徵象時，下列何項防護設備較不必要？",5,{"webId":45,"stem":46,"number":47,"year":28,"session":23},"nurse-106-1-fundamental-nursing-006","林小姐因中風導致右側肢體偏癱，住院期間有關病人之安全，下列敘述何者錯誤？",6,1783840750108]