[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-108-1-medical-surgical-076":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":61},"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-108-1-內外科護理學-076","nurse-108-1-medical-surgical-076",108,1,76,"依據吳先生的症狀與徵象估計其失血量，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"少於 750 mL","大於或等於 750～1500 mL","大於 1500～2000 mL","大於 2000 mL","C",null,[],"本題考點為以生命徵象估計出血分級（失血量）。依創傷高級救命術的出血分級，第三級出血（Class III）約流失血量 1500～2000 mL（約占總血量 30～40%），典型表現為心跳大於 120、呼吸 30～40、血壓開始下降、意識焦慮；吳先生心跳 130、呼吸 35、血壓 90\u002F60 正好落在此級，故選 C「大於 1500～2000 mL」。選項 A「少於 750 mL」屬第一級，生命徵象幾乎正常，不符。選項 B「750～1500 mL」屬第二級，心跳 100～120、血壓仍可維持，程度較輕。選項 D「大於 2000 mL」屬第四級，血壓顯著崩塌、意識昏沉、已近瀕危，比本題表現更嚴重。","創傷出血四級對照（以 70 kg 成人約 5000 mL 血量計）：Class I ＜15%（＜750 mL），生命徵象正常；Class II 15～30%（750～1500 mL），心搏過速、脈壓變窄；Class III 30～40%（1500～2000 mL），血壓下降、意識焦躁；Class IV ＞40%（＞2000 mL），瀕死。判讀關鍵順序：脈壓變窄與心跳加快最早出現，收縮壓下降是較晚期徵象。記憶重點：血壓一旦掉，失血已達三成以上。連結概念：脈壓、代償性休克、微血管充填時間。",[24,27,29,31],{"term":25,"count":26},"脈壓變窄",2,{"term":28,"count":10},"創傷出血分級",{"term":30,"count":10},"Class III出血",{"term":32,"count":10},"生命徵象與失血量",[34,38,43,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-108-1-medical-surgical-077","依據吳先生的症狀與徵象，所執行之立即處置，下列何者不適宜？",77,{"webId":39,"stem":40,"number":41,"year":42,"session":10},"nurse-109-1-medical-surgical-013","有關風濕熱之敘述，下列何者正確？①最常侵犯三尖瓣 ②須使用抗生素治療 ③應多從事體能活動以強化心臟功能 ④若有心衰竭症狀須採低鹽飲食",13,109,{"webId":44,"stem":45,"number":46,"year":42,"session":26},"nurse-109-2-medical-surgical-027","心包填塞（cardiac tamponade）之臨床表徵，下列何者正確？①低沉的心音 ②中心靜脈壓上升 ③奇異脈 ④脈搏壓變寬",27,{"webId":48,"stem":49,"number":50,"year":51,"session":26},"nurse-110-2-medical-surgical-065","有關急迫性尿失禁的護理措施，下列何者最不適當？",65,110,{"webId":53,"stem":54,"number":55,"year":56,"session":10},"nurse-112-1-medical-surgical-029","有關心律不整病人照護之敘述，下列何者錯誤？",29,112,{"webId":58,"stem":59,"number":41,"year":60,"session":10},"nurse-113-1-medical-surgical-013","有關下背痛病人使用骨盆牽引治療之敘述，下列何者正確？",113,"2026-09-04",1788510710174]