[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-108-2-fundamental-nursing-049":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":62},"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":11},"nurse-108-2-基本護理學與護理行政-049","nurse-108-2-fundamental-nursing-049",108,2,49,"李先生因左小腿脛骨處有一 5 %TBSA 燒傷，進行分層皮膚移植（split-thickness graft, STSG），術後以短腿石膏夾板固定，有關包紮注意事項，下列敘述何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"包紮應從遠心端朝近心端包紮","足踝處置放棉墊再包紮，以減少摩擦及受壓","包紮完成後，結帶固定於左小腿前方","檢查足部的溫度、顏色、麻木感","C",null,[],"本題考點是分層皮膚移植（STSG）術後石膏夾板包紮的注意事項，選錯誤者為C。固定用的結帶不可打結於傷口／植皮處或骨突正上方，以免局部受壓影響皮瓣血流與癒合；左小腿前方正是脛骨（骨突）與植皮區所在，將結帶固定於此為錯誤（C）。A由遠心端往近心端包紮有助靜脈回流、減少腫脹；B足踝骨突處先墊棉墊以減少摩擦與受壓；D須監測足部溫度、顏色與麻木感以評估末梢循環及神經壓迫，此三者皆正確。故答案C。","植皮術後包紮的核心是「維持皮瓣貼合、避免剪力與壓迫、確保血流」。結帶（固定帶）打結位置應避開傷口、骨突與植皮區，通常固定於肢體側面軟組織處；打在脛骨前（骨突＋植皮）會造成點狀壓力導致皮瓣壞死或壓傷。遠心端往近心端纏繞順應靜脈回流方向可減輕水腫。神經血管評估（5P：pain、pallor、pulselessness、paresthesia、paralysis）用以及早發現石膏過緊或腔室症候群。分層皮膚移植取表皮＋部分真皮，需靠受區血管新生（blood plasma imbibition→inosculation→revascularization）存活，故初期制動與避壓格外重要。",[25,27,30,32],{"term":26,"count":11},"末梢神經血管評估",{"term":28,"count":29},"分層皮膚移植STSG",1,{"term":31,"count":29},"結帶避開骨突與植皮處",{"term":33,"count":29},"遠心端至近心端包紮",[35,39,44,48,53,57],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-108-2-fundamental-nursing-050","一位長期服用furosemide（Lasix ○ R ）、Warfarin ○ R 的病人，其飲食衛教下列何者適當？",50,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-109-1-fundamental-nursing-066","下列何者不是功能性護理的優點？",66,109,{"webId":45,"stem":46,"number":47,"year":43,"session":11},"nurse-109-2-fundamental-nursing-080","有關醫院評鑑實地訪查之敘述，下列何者正確？①決定優先查證重點 ②以病人為焦點的查證方式（patient focus method；PFM）案例追查 ③交叉查證 ④審核申報健保給付",80,{"webId":49,"stem":50,"number":51,"year":52,"session":29},"nurse-111-1-fundamental-nursing-038","關於影響呼吸速率之相關因素的敘述，下列何者正確？",38,111,{"webId":54,"stem":55,"number":11,"year":56,"session":11},"nurse-112-2-fundamental-nursing-002","張簡女士頭痛、嘔吐，意識清醒有自決能力，由其先生與小兒子送至急診，診斷後懷疑顱內高壓，欲進行核磁造影（MRI）協助診察。下列何人是簽署「核磁造影檢查同意書」的第一順位？",112,{"webId":58,"stem":59,"number":60,"year":61,"session":11},"nurse-113-2-fundamental-nursing-016","輸血時發生咳嗽、心搏過速、高血壓及呼吸困難症狀，最有可能發生下列何種反應？",16,113,"2026-09-04",1788510705937]