# 一位嚴重營養不良的個案昨日開始接受腸道營養。今天，個案主訴新發生的肌肉無力，且血清磷濃度從 3.4 mg/dL 降至 1.1 mg/dL。護理師應採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498498&lang=zh-tw > language: zh-TW > subject: Postsurgical Complications > category: ROR ## 題目 一位嚴重營養不良的個案昨日開始接受腸道營養。今天，個案主訴新發生的肌肉無力，且血清磷濃度從 3.4 mg/dL 降至 1.1 mg/dL。護理師應採取哪項行動？ ## 選項 1. 暫停進一步增加灌食速率並立即通知醫師 **✔ 正確答案** 2. 增加灌食速率以達到處方的熱量目標 3. 給予額外的自由水並於明日重複檢驗 4. 將此發現記錄為腸道營養的預期反應 **正確答案: 1** ## 解析 重新開始熱量後不久出現明顯的磷下降伴隨無力，暗示再餵食症候群。應暫停進一步增加熱量，同時通知醫師並處理電解質補充與營養管理。 ## 深入解析 快速解答 暫停進一步增加灌食並立即通知醫師。重新引入熱量後突然發生的低血磷和無力是再餵食症候群的警訊。 為什麼這是正確的 營養不良的身體細胞內電解質已耗盡。當熱量重新開始時，胰島素會將磷驅入細胞內，血清濃度可能下降到足以損害肌肉、呼吸和心臟功能，除非調整灌食和補充。 簡單比喻或心智圖像 再餵食就像在倉庫貨架空無一物後重新啟動工廠：突然全面生產會過快地消耗剩餘的材料。這個比喻說明了謹慎增加速度，但實際照護需根據檢驗趨勢和個別化電解質治療。 記憶掛鉤 熱量重新開始，磷移入細胞，無力出現：暫停增加速度並通報。 NCLEX 決策規則 當嚴重營養不良的個案在重新開始熱量後數天內出現快速的磷、鉀或鎂下降，應懷疑再餵食症候群。透過暫停增加速度並立即協調電解質和營養管理來防止進一步惡化。 為什麼其他選項是錯的 增加熱量可能加劇電解質轉移。自由水無法矯正磷的耗盡，等到明天會延誤治療，而嚴重低血磷伴隨無力並非預期的無害反應。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]ASPEN Consensus Recommendations for Refeeding SyndromePubMed, National Library of Medicine ## 相同主題題目 - [A 24-year-old patient is brought to the ED with a generalized tonic-clonic seizure that ha…](https://mymerci.kr/pages/nclex_q.php?qn_id=372718&lang=zh-tw) - [A 28-year-old patient with a T4 spinal cord injury 3 months ago is admitted with sudden se…](https://mymerci.kr/pages/nclex_q.php?qn_id=372742&lang=zh-tw) - [A patient who sustained blunt chest trauma 30 minutes ago is now in extreme respiratory di…](https://mymerci.kr/pages/nclex_q.php?qn_id=372743&lang=zh-tw) - [Two hours after abdominal surgery, a client has a saturated dressing, heart rate 126/min, …](https://mymerci.kr/pages/nclex_q.php?qn_id=393732&lang=zh-tw) - [A client scheduled for surgery tomorrow says, "I took my warfarin this morning like usual.…](https://mymerci.kr/pages/nclex_q.php?qn_id=394155&lang=zh-tw) - [A client is 6 hours postoperative after a thyroidectomy and develops stridor with increasi…](https://mymerci.kr/pages/nclex_q.php?qn_id=396608&lang=zh-tw) - [A client 2 hours after abdominal surgery has a heart rate of 122/min, blood pressure 86/50…](https://mymerci.kr/pages/nclex_q.php?qn_id=397167&lang=zh-tw) - [A client 12 hours after thyroidectomy reports tingling around the mouth and muscle cramps.…](https://mymerci.kr/pages/nclex_q.php?qn_id=397280&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498498&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498498&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498498&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498498&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498498&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_