[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-107-1-fundamental-nursing-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":33,"lastmod":63},"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":11},"nurse-107-1-基本護理學與護理行政-055","nurse-107-1-fundamental-nursing-055",107,1,55,"趙先生 72 歲，診斷 COPD，此次因呼吸困難入院，監測血氧飽和度 88%，護理師為病人進行初次評估時，下列何者最適當？",{"A":15,"B":16,"C":17,"D":18},"先收集完整性的健康史，再決定處理病人健康問題的優先次序","先執行完整性身體檢查與評估，了解呼吸困難對其全身所造成的影響","先處理呼吸困難的相關問題，等情況穩定再執行完整性身體檢查與評估","先執行完整性身體檢查與評估，再詢問家屬有關這次發生呼吸困難之相關訊息","C",null,[],"本題考點是評估與處置的優先次序判斷。依危及生命問題優先（ABC 原則）的照護邏輯，趙先生 COPD 併呼吸困難、血氧飽和度僅 88%，屬急性缺氧、危及生命的狀況，護理師應先介入處理呼吸困難、待情況穩定後再進行完整身體檢查與評估，故 C 最適當。A 錯在先收集完整健康史：病情危急時不能先做費時的資料收集。B 與 D 都主張先執行完整性身體檢查與評估，等於把耗時的全面評估排在緊急處置之前，會延誤氧合改善的時機；D 又把詢問家屬置於處置前，更顯本末倒置。緊急下應『先穩定生命徵象、再全面評估』。","臨床決策採兩種評估模式：病情穩定時做『完整性評估（comprehensive）』，病情危急時做『焦點式\u002F緊急評估（focused \u002F emergency）』先鎖定威脅生命的問題。判準是生命徵象：SpO2 88% 已低於一般 90% 警戒（COPD 病人目標仍多設 88–92%，但合併明顯呼吸困難即需介入）。優先次序口訣『先救命、後求全』：ABC（Airway-Breathing-Circulation）永遠排在完整病史與全身理學檢查之前。此題型只要看到『急性、危及生命』字眼，就選先處理症狀的選項。",[25,27,29,31],{"term":26,"count":11},"ABC 優先原則",{"term":28,"count":11},"焦點式評估",{"term":30,"count":11},"COPD 缺氧",{"term":32,"count":11},"處置優先次序",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":10,"session":11},"nurse-107-1-fundamental-nursing-056","陳先生，意識清楚，診斷腎絲球腎炎，醫師開立收集 24 小時尿液作肌酸酐廓清（CCr）試驗之醫囑，下列尿液收集程序何者最正確？",56,{"webId":39,"stem":40,"number":41,"year":10,"session":42},"nurse-107-2-fundamental-nursing-072","為訓練護理師專業知識、技能，以提供病人整合性與連續性照護。設立下列何種委員會較為適合？",72,2,{"webId":44,"stem":45,"number":46,"year":47,"session":42},"nurse-108-2-fundamental-nursing-006","有關病人接受冷敷或熱敷，下列敘述何者正確？",6,108,{"webId":49,"stem":50,"number":51,"year":52,"session":42},"nurse-109-2-fundamental-nursing-044","下列藥物作用何者不會干擾睡眠週期？",44,109,{"webId":54,"stem":55,"number":56,"year":57,"session":11},"nurse-111-1-fundamental-nursing-008","王先生進行全喉切除手術，術後僅能以書寫溝通。王先生多次以書寫方式溝通，護理師皆無法了解，王先生於是無奈地向護理師擺擺手，轉頭留下眼淚。依據伯儂（Berlo）溝通模式，下列敘述何者正確？",8,111,{"webId":59,"stem":60,"number":61,"year":62,"session":11},"nurse-112-1-fundamental-nursing-042","王先生因車禍入院，前額有撕裂傷、左側手腳骨折、右前臂靜脈注射 0.9% N\u002FS I.V.F. 60 c.c.\u002Fhr、意識混亂，以簡單面罩提供氧氣，下列何者是測量血壓及體溫最適宜部位？",42,112,"2026-09-04",1788510702189]