[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-107-1-medical-surgical-005":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"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-107-1-內外科護理學-005","nurse-107-1-medical-surgical-005",107,1,5,"江小姐因頸椎滑脫須使用床頭式骨骼牽引 Gardner-Wells Tongs traction 讓頸椎復位，下列敘述何者正確？",{"A":14,"B":15,"C":16,"D":17},"為讓頸椎及早復位，砂袋的重量越重越好","裝上牽引後，第 2 天再照頸椎的 X-ray","骨釘處每天應用優碘消毒 3 次","牽引移除時應採漸進方式，不可以一次完全移除砂袋","D",null,[],"本題考點是頸椎骨骼牽引(Gardner-Wells Tongs)的照護原則。依骨骼牽引須維持持續且穩定的拉力，移除時若一次卸除全部砝碼，肌肉與韌帶失去對抗會使頸椎再度位移，故應採漸進減重方式，D正確。A「重量越重越好」錯，過重會造成過度牽張或神經血管損傷，須依醫囑逐步調整;B「第2天再照 X 光」錯，牽引後應即刻攝影確認復位與砝碼安全;C「骨釘處每天優碘消毒3次」的例行頻率並非標準骨釘照護準則，故非正確答案。","骨骼牽引的鐵律是「持續、對抗、不落地」:砝碼須自由懸空、繩索在滑輪溝內、拉力線與骨骼長軸一致,且任何時候不可自行加減砝碼。Gardner-Wells Tongs 是插入頭顱兩側顳骨的鉗夾式牽引,用於頸椎骨折脫位復位。骨釘照護(pin care)重點在觀察感染徵象與依機構規範清潔,而非硬性規定每日三次優碘。相對於皮膚牽引(如 Buck's),骨骼牽引可承受更大且長時間的重量,護理需加強神經血管評估與預防制動併發症。",[24,27,29,31],{"term":25,"count":26},"骨骼牽引原則",2,{"term":28,"count":10},"Gardner-Wells Tongs",{"term":30,"count":10},"漸進移除牽引",{"term":32,"count":10},"骨釘照護",[34,38,42,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-107-1-medical-surgical-006","有關中風病人功能性尿失禁問題的敘述，下列何者正確？①建立讓病人有表達如廁需要的溝通方法 ②儘量包著尿布以避免因為失禁引起病人的困窘 ③應存放留置尿管以預防尿液滯留 ④白天每 2～3 小時協助病人如廁一次",6,{"webId":39,"stem":40,"number":41,"year":9,"session":26},"nurse-107-2-medical-surgical-022","有關青光眼藥物作用的敘述，下列何者正確？",22,{"webId":43,"stem":44,"number":45,"year":46,"session":10},"nurse-108-1-medical-surgical-036","與乳癌有關的腫瘤標記，下列何者正確？",36,108,{"webId":48,"stem":49,"number":50,"year":51,"session":10},"nurse-109-1-medical-surgical-074","有關監測敗血症病人液體療法之生理指標，下列何者最可能需調節輸液？",74,109,{"webId":53,"stem":54,"number":55,"year":56,"session":26},"nurse-110-2-medical-surgical-038","有關何杰金氏淋巴瘤的敘述，下列何者錯誤？",38,110,{"webId":58,"stem":59,"number":60,"year":61,"session":26},"nurse-111-2-medical-surgical-072","有關高滲透壓高血糖狀態（HHS）的敘述，下列何者正確？",72,111,"2026-09-04",1788510702454]