[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-106-2-medical-surgical-077":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"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-106-2-內外科護理學-077","nurse-106-2-medical-surgical-077",106,2,77,"針對心臟衰竭病人的評估結果，下列何者最需要護理師密切觀察？",{"A":14,"B":15,"C":16,"D":17},"下肢水腫","呼吸音出現囉音（rales）","血壓 146\u002F88 mmHg","微血管再填充試驗（capillary refill test）小於 3 秒","B",null,[],"本題考點在心臟衰竭病人評估的優先順序（依 ABC 與危急程度排序）。呼吸音出現囉音（rales／crackles）代表肺水腫、肺泡內積液，是左心衰竭急性惡化、氣體交換受損的危急徵象，直接威脅呼吸與氧合，最需密切觀察，選 B。A 下肢水腫反映右心衰竭體液滯留，屬慢性、非立即危及生命；C 血壓 146\u002F88 mmHg 僅輕度偏高，非急迫；D 微血管再填充試驗小於 3 秒屬正常灌流表現，反而是好現象。依「危及氣道呼吸者優先」原則，肺部囉音最應優先評估。","左右心衰竭定位：左心衰竭「往後塞回肺」造成肺鬱血、囉音、端坐呼吸、陣發性夜間呼吸困難；右心衰竭「往後塞回體循環」造成頸靜脈怒張、肝腫大、下肢水腫。急性肺水腫是內科急症，處置口訣 LMNOP（Lasix 利尿、Morphine、Nitrates、Oxygen、Position 端坐）。臨床評估排序遵循 ABC——影響呼吸氧合的線索永遠優先於周邊水腫或輕度血壓變動。capillary refill \u003C3 秒為正常值，屬干擾選項。",[24,27,29,31,33],{"term":25,"count":26},"左心衰竭肺水腫",1,{"term":28,"count":26},"囉音rales\u002Fcrackles",{"term":30,"count":26},"ABC評估優先順序",{"term":32,"count":26},"右心衰竭下肢水腫",{"term":34,"count":26},"微血管再填充正常值",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-106-2-medical-surgical-078","有關末期腎疾病（ESRD）病人，因腎性貧血接受紅血球生成素（EPO）治療之準則，下列何者錯誤？",78,{"webId":41,"stem":42,"number":43,"year":44,"session":10},"nurse-107-2-medical-surgical-014","王先生，25 歲，今早突感肚臍周圍疼痛且有噁心、食慾不振的現象，至醫院求診，護理師評估疼痛位置轉移到右下腹，懷疑為急性闌尾炎，下列何項檢查可明確確定病人問題？",14,107,{"webId":46,"stem":47,"number":48,"year":49,"session":26},"nurse-108-1-medical-surgical-028","下列病人描述何者不是穩定型心絞痛疼痛之典型特徵？",28,108,{"webId":51,"stem":52,"number":53,"year":54,"session":26},"nurse-109-1-medical-surgical-066","有關高滲透壓高血糖狀態（HHS）之敘述，下列何者正確？",66,109,{"webId":56,"stem":57,"number":58,"year":59,"session":10},"nurse-110-2-medical-surgical-030","有關心電圖的敘述，下列何者錯誤？",30,110,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-111-2-medical-surgical-064","有關腎臟癌的敘述，下列何者正確？",64,111,"2026-09-04",1788510698991]