[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-107-2-fundamental-nursing-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":64},"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-107-2-基本護理學與護理行政-055","nurse-107-2-fundamental-nursing-055",107,2,55,"尤先生，66 歲，診斷慢性阻塞性肺疾病（chronic obstructive pulmonary disease, COPD），因呼吸喘、發燒，由急診送入病房，其立即性的入院護理包括：①監測生命徵象 ②病房環境介紹 ③測量身高體重 ④測量血氧飽和度 ⑤教導呼叫鈴使用 ⑥教導檢體收集方法與檢體放置處",{"A":15,"B":16,"C":17,"D":18},"①②③","①④⑤","②④⑥","④⑤⑥","B",null,[],"本題考點在急診轉入 COPD 病人的立即性入院護理優先順序。依 ABC（呼吸道、呼吸、循環）優先原則，尤先生呼吸喘、發燒，最急需的是①監測生命徵象、④測量血氧飽和度以掌握呼吸與氧合狀態，以及⑤教導呼叫鈴使用確保病人有需要時能即時求助，故選 B①④⑤。②病房環境介紹、③測量身高體重、⑥教導檢體收集與放置屬一般入院衛教與非急迫評估，可於病情穩定後再進行，並非「立即性」處置。三個非答案項目皆非攸關即時安全的優先事項，唯 B 組合聚焦生理監測與病人安全。","入院護理分「立即性」與「後續性」：立即性以維持生命與安全為主（生命徵象、血氧、必要監測、確保求助管道即呼叫鈴），COPD 急性發作更要盯 SpO2 與呼吸型態，且給氧須留意二氧化碳滯留者的低氧驅動、避免過高氧濃度。身高體重、環境介紹、檢體衛教屬穩定後的例行事項。口訣：「先命後教、先急後緩」。COPD 目標血氧常設 88～92%，是延伸複習重點。",[25,28,30,32],{"term":26,"count":27},"ABC 優先順序",1,{"term":29,"count":27},"立即性入院護理",{"term":31,"count":27},"血氧飽和度監測",{"term":33,"count":27},"病人安全與呼叫鈴",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-107-2-fundamental-nursing-056","有關痰液常規檢查之敘述，下列何者錯誤？",56,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-108-1-fundamental-nursing-072","護理部門實施護理人員在職教育及護理技術稽核，其目的是為了要滿足下列那項護理評鑑範疇？",72,108,{"webId":45,"stem":46,"number":47,"year":48,"session":27},"nurse-109-1-fundamental-nursing-006","王護理師在白班下班前書寫護理紀錄，內容為：「9 AM T.P.R BP：37.3℃、75 次\u002F分、20 次\u002F分、 128\u002F70 mmHg，於 9：30 Am 主訴已經 4 天未解便，通知 Dr.張，by order 給予 Dulcolax 1# supp. st，在 11：00 Am 解出少許顆粒狀大便，續觀察中\u002FN2 王小美」此護理紀錄最不符合那一項記錄原則？",6,109,{"webId":50,"stem":51,"number":52,"year":53,"session":27},"nurse-110-1-fundamental-nursing-044","承上題，包紮完畢後，可於下列何處結帶固定？",44,110,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-111-2-fundamental-nursing-008","下列何項屬於治療性溝通技巧？ ①反映（Reflecting） ②重述（Restating） ③猜測（Questioning） ④批判（Criticize）",8,111,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-112-2-fundamental-nursing-042","關於測量血壓的技術之敘述，下列何者正確？",42,112,"2026-09-04",1788510724652]