[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-108-2-fundamental-nursing-023":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":63},"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-108-2-基本護理學與護理行政-023","nurse-108-2-fundamental-nursing-023",108,2,23,"王先生為脊髓損傷病人，臀部有一久未癒合 10×8×4 cm 3 的傷口，入院時抱怨：「傷口都好幾個月了，怎麼都不會好？」。下列何者為護理師應最優先執行之護理措施？",{"A":15,"B":16,"C":17,"D":18},"給予傷口換藥，以保濕性敷料覆蓋","以住院期間能改善傷口大小為照顧目標","評估影響王先生傷口癒合的因素","住院飲食採高蛋白、富維生素 C 食物","C",null,[],"本題考點為護理過程的步驟順序:評估—診斷—計畫—執行—評值,任何處置前須先完整評估。傷口數月未癒暗示背後有未解決的影響因素(如營養不良、組織灌流不足、感染、持續受壓、血糖失控),護理師應最優先評估影響王先生傷口癒合的因素,據此擬定後續照護,選C。A傷口換藥、D高蛋白高維生素C飲食屬執行層面的措施,B以改善傷口大小為目標屬設定目標,三者都應建立在評估結果之上。未評估即處置可能治標不治本,故評估先行。","傷口癒合受全身與局部因素交互影響:全身面向有營養(蛋白質、維生素C與鋅)、血糖控制、組織灌流與含氧、年齡、用藥(類固醇);局部面向有壓力\u002F剪力、感染、濕度、異物與壞死組織。脊髓損傷者因感覺喪失、長期臥床與失禁,壓力性損傷難癒。護理過程強調「評估先於措施」,先找出癒合停滯的主因(如持續受壓或低蛋白),介入才有效。傷口評估要素:大小、深度、傷口床(肉芽\u002F腐肉\u002F焦痂)、滲液與周圍皮膚。",[25,28,30,33],{"term":26,"count":27},"護理過程",11,{"term":29,"count":11},"壓力性損傷",{"term":31,"count":32},"評估先於措施",1,{"term":34,"count":32},"傷口癒合影響因素",[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-108-2-fundamental-nursing-024","護理師對非急性期腦中風偏癱的病人，擬定每天 2 次與家屬一起協助病人執行下床練習走路，是屬於下列那一項護理措施？",24,{"webId":41,"stem":42,"number":43,"year":44,"session":32},"nurse-109-1-fundamental-nursing-040","一位 75 歲男性、身材適中、有心房纖維震顫、高血壓及梗塞性腦中風導致右側肢體偏癱的住院病人，目前左手注射 D 5 W+KCL 10 mEq 40 c.c.\u002F小時，以電子血壓計測量血壓，下列有關血壓和脈搏測量，何者最適當？",40,109,{"webId":46,"stem":47,"number":48,"year":44,"session":11},"nurse-109-2-fundamental-nursing-054","當瀕死病人時常出現哭泣行為，處於憂鬱期時之護理措施，下列何者最適當？①減少探視病人的次數，讓其獨處減少干擾 ②移除室內具有自我傷害的危險物品 ③鼓勵其表達內心害怕，允許哭泣 ④告訴她憂愁也無濟於事，應該正向看待",54,{"webId":50,"stem":51,"number":52,"year":53,"session":32},"nurse-111-1-fundamental-nursing-012","盧女士行乳房切除術，乏人照料，護理人員親自為其進行床上沐浴時，蒐集到下列資料，何者屬於急性疼痛的主觀資料？",12,111,{"webId":55,"stem":56,"number":57,"year":58,"session":32},"nurse-112-1-fundamental-nursing-056","護理師向病患及其家屬說明安寧緩和療護，下列何種情況無法使用健保給付的安寧照護？",56,112,{"webId":60,"stem":61,"number":43,"year":62,"session":32},"nurse-113-1-fundamental-nursing-040","醫院擬新建醫療大樓，現有病房需進行科別變更或縮減床位，護理主任為因應改變，下列何者應優先執行？",113,"2026-09-04",1788510705702]