[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-107-1-medical-surgical-077":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":36,"lastmod":66},"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-077","nurse-107-1-medical-surgical-077",107,1,77,"劉小弟 13 歲，至海邊戲水不慎發生溺水，到達急診時體溫：34℃、心跳：102 次\u002F分、呼吸：32 次\u002F分、血壓：80\u002F60 mmHg，呼吸音出現瀰漫性水泡音，胸部 X 光呈現肺水腫。依據上述資料，以臺灣急診檢傷急迫度分級量表（TTAS）判斷病人目前溺水之嚴重程度，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"2 級","3 級","4 級","5 級","A","第77題答Ａ給分",[],"本題考點為以臺灣急診檢傷急迫度分級量表(TTAS)判讀溺水個案的危急程度。TTAS共五級,第1級復甦、第2級危急、第3級緊急、第4級次緊急、第5級非緊急。本例呈現血壓80\u002F60 mmHg偏低、呼吸32次\u002F分且有瀰漫性水泡音、胸部X光肺水腫、體溫34℃低體溫,顯示呼吸窘迫合併血流動力學不穩、有立即惡化風險,依TTAS屬第2級「危急」,故選A。3級(B)、4級(C)、5級(D)適用於生命徵象相對穩定者,與本例的呼吸循環危象不符。","TTAS依主訴分類再結合生命徵象與危險徵象決定級數:第1級為心跳停止、無呼吸等需立即復甦者;第2級為有立即生命威脅、需10分鐘內處置,如嚴重呼吸窘迫、血流動力學不穩、意識急劇改變。本例低血壓+肺水腫+低體溫符合第2級。溺水病人核心風險是缺氧與非心因性肺水腫,加上低體溫,屬高危險;判級時抓住「有無立即危及呼吸循環」即可快速定位。",[24,27,30,32,34],{"term":25,"count":26},"肺水腫",9,{"term":28,"count":29},"TTAS檢傷分級",3,{"term":31,"count":10},"溺水",{"term":33,"count":10},"呼吸窘迫",{"term":35,"count":10},"血流動力學不穩",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":9,"session":10},"nurse-107-1-medical-surgical-078","承上題，有關劉小弟的照護措施，下列何者錯誤？",78,{"webId":42,"stem":43,"number":44,"year":45,"session":10},"nurse-108-1-medical-surgical-014","有關橫膈食道裂孔疝氣的臨床表徵，下列何者錯誤？",14,108,{"webId":47,"stem":48,"number":49,"year":45,"session":50},"nurse-108-2-medical-surgical-028","評估脈搏強度時，發現「很難摸得到，脈搏明顯的減弱」，下列紀錄何者正確？",28,2,{"webId":52,"stem":53,"number":54,"year":55,"session":50},"nurse-109-2-medical-surgical-066","有關腎臟所製造荷爾蒙的生理功能，下列何者正確？",66,109,{"webId":57,"stem":58,"number":59,"year":60,"session":10},"nurse-111-1-medical-surgical-030","有關心因性休克之敘述，下列何者錯誤？",30,111,{"webId":62,"stem":63,"number":64,"year":65,"session":10},"nurse-112-1-medical-surgical-064","王先生的動脈血液氣體分析判讀結果為未代償性呼吸性酸中毒，下列敘述何者正確？",64,112,"2026-09-04",1788510703205]