[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-107-2-medical-surgical-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":65},"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-107-2-內外科護理學-055","nurse-107-2-medical-surgical-055",107,2,55,"有關氣管內插管病人之護理措施，下列何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"定時評估病人抽痰的需要以維持管路通暢","維持氣管內管氣囊壓力在 35 mmHg 以預防管路滑脫","灌食時搖高病人床頭 30～45 度以避免吸入性肺炎","依醫囑給與鎮靜劑以預防非預期性拔管","B",null,[],"本題考點在氣管內插管的氣囊壓力管理。依標準,氣管內管氣囊壓力應維持約 20～25 mmHg(或 25～30 cmH₂O),目的是密封氣道以防漏氣與吸入,而非防止管路滑脫;壓力過高(如 35 mmHg)會超過氣管黏膜微血管灌流壓,造成黏膜缺血、壞死甚至氣管軟化狹窄,故錯誤者選 B。選項 A 定時評估抽痰以維持管路通暢,正確;選項 C 灌食時床頭抬高 30～45 度可降低胃內容物逆流與吸入性肺炎,正確;選項 D 依醫囑給鎮靜劑以降低躁動、預防非計畫性拔管,正確。","氣囊(cuff)功能是封閉氣管壁與管壁間隙,確保正壓通氣不漏氣並阻擋口咽分泌物下滲,固定管路靠的是牙墊與膠布而非氣囊。氣管黏膜微血管灌流壓約 25～35 mmHg,cuff 壓超過即壓迫缺血,故臨床以測壓計維持在安全範圍並定期監測。口訣:cuff 防漏防吸入,壓力寧低勿高。",[24,27,30,33],{"term":25,"count":26},"吸入性肺炎預防",4,{"term":28,"count":29},"氣管內插管",3,{"term":31,"count":32},"氣囊壓力",1,{"term":34,"count":32},"氣管黏膜灌流",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-107-2-medical-surgical-056","以鼻套管 4 L\u002Fmin 所提供的氧氣濃度約為何？",56,{"webId":41,"stem":42,"number":43,"year":44,"session":32},"nurse-108-1-medical-surgical-072","有關庫欣氏症候群的診斷檢查，下列何者最具特異性？",72,108,{"webId":46,"stem":47,"number":48,"year":49,"session":32},"nurse-109-1-medical-surgical-006","75 歲老人最近心情抑鬱，對外在環境興趣缺缺，腦部電腦斷層顯示腦組織萎縮、腦溝變大，下列何者為其最可能診斷？",6,109,{"webId":51,"stem":52,"number":53,"year":54,"session":32},"nurse-110-1-medical-surgical-044","下列皮膚病灶何者是原發性皮膚病變？",44,110,{"webId":56,"stem":57,"number":58,"year":59,"session":10},"nurse-111-2-medical-surgical-008","有關內視鏡椎間盤切除術的敘述，下列何者錯誤？",8,111,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-112-2-medical-surgical-042","有關癌症疼痛處置之敘述，下列何者正確？",42,112,"2026-09-04",1788510725393]