[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-107-1-fundamental-nursing-021":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":66},"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-107-1-基本護理學與護理行政-021","nurse-107-1-fundamental-nursing-021",107,1,21,"謝小姐因大量嘔吐及腹痛入急診求診，診斷為急性腸胃炎，目前禁食且靜脈輸液 5%葡萄糖及 0.9% 食鹽水溶液（D 5 S）中。謝小姐有體液容積缺失的情形，此情形與下列何種檢查數值無關？",{"A":15,"B":16,"C":17,"D":18},"脈搏 100 次\u002F分","WBC：12,000\u002Fmm 3","24 小時尿量 500 mL","BP：90\u002F60 mmHg","B",null,[],"本題考點在辨識「體液容積缺失(fluid volume deficit)」的臨床指標。依循環血量不足的代償生理,血量下降會使心跳加速以維持心輸出量、腎臟減少排尿以保留水分、血壓因回心血量減少而下降,故脈搏100次\u002F分(A)、24小時尿量僅500mL(C)、血壓90\u002F60(D)三者皆與體液缺失直接相關。白血球12,000\u002Fmm³(B)反映的是感染或發炎反應(急性腸胃炎本身即會使WBC上升),屬免疫指標而非體液容積指標,與缺水程度無直接因果,故選B為「無關」者。","體液容積缺失時,血比容(Hct)、血中尿素氮(BUN)與尿比重會因血液濃縮而上升,尿量減少(\u003C30mL\u002Fhr為警訊)。WBC雖可能因濃縮略升,但升高主因是感染而非缺水。記憶:低血容量三徵=心搏快、血壓低、尿量少,合稱循環代償警訊。",[25,28,30,32,34],{"term":26,"count":27},"體液容積缺失",3,{"term":29,"count":11},"血液濃縮",{"term":31,"count":11},"代償性心搏過速",{"term":33,"count":11},"少尿",{"term":35,"count":11},"白血球與感染",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-107-1-fundamental-nursing-022","王先生術後第一天正接受大量靜脈輸液，護理師發現點滴的滴速時慢時停，下列處置措施何者錯誤？",22,{"webId":42,"stem":43,"number":44,"year":10,"session":45},"nurse-107-2-fundamental-nursing-038","江小姐，參與路跑活動後，出現大量流汗、皮膚蒼白濕冷、血壓降低、脈搏快而弱、頭痛及噁心的現象，下列敘述何者正確？①江小姐出現熱衰竭的情形 ②江小姐出現中暑的情形 ③稍微將下肢抬高 ④頭部稍為墊高",38,2,{"webId":47,"stem":48,"number":49,"year":50,"session":11},"nurse-108-1-fundamental-nursing-052","有關血液培養（blood culture）之血液採集過程，下列敘述何者正確？",52,108,{"webId":52,"stem":53,"number":54,"year":55,"session":45},"nurse-109-2-fundamental-nursing-010","孫先生昨天開始解尿不順、尿道灼熱感，臉色發紅、皮膚溫暖乾燥，生命徵象：血壓 126 \u002F 76 mmHg、體溫 39.2°C（耳溫）、脈搏 116 次／分、呼吸 26 次／分，孫先生出現發燒現象，下列護理措施何者不適當？",10,109,{"webId":57,"stem":58,"number":59,"year":60,"session":45},"nurse-110-2-fundamental-nursing-054","有關死亡後的遺體變化，下列敘述何者正確？",54,110,{"webId":62,"stem":63,"number":64,"year":65,"session":11},"nurse-112-1-fundamental-nursing-008","有關護理紀錄書寫的內容，下列何者最適宜？",8,112,"2026-09-04",1788510701881]