[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-108-2-medical-surgical-045":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"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":10},"nurse-108-2-內外科護理學-045","nurse-108-2-medical-surgical-045",108,2,45,"有關燒傷病人的緊急處理措施 5 步驟之敘述，下列何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"沖：以流動的冷水沖患部","脫：用剪刀移除衣物，若衣物與傷口沾黏，勿強行脫除","泡：將患部泡在冰水中降溫，將餘熱去除減輕疼痛感","蓋：以乾淨的衣物、毛毯、紗布等覆蓋，保存體溫且避免污染傷口","C",null,[],"本題考點是燒傷急救「沖脫泡蓋送」五步驟的正確作法,找出錯誤者。依燒傷急救原則,第三步「泡」應以微涼或常溫的清水(冷水)持續浸泡降溫,不可使用冰水或冰塊,因冰水會使局部血管過度收縮、加重組織缺血傷害並引發全身失溫,故 C 稱「泡在冰水中」為錯誤,選 C。A 以流動冷水沖患部降溫,正確。B 用剪刀移除衣物、沾黏處不強行撕除以免二次傷害,正確。D 以乾淨衣物毛毯紗布覆蓋、保暖並防污染,正確。考點在於辨識「冷水非冰水」的降溫界線。","口訣沖脫泡蓋送:沖(流動冷水沖 15～30 分)、脫(小心去除衣物飾品)、泡(冷水持續浸泡)、蓋(乾淨布覆蓋)、送(儘速就醫)。用冰敷或冰水會造成血管收縮加深組織壞死並致低體溫,尤其大面積燒傷禁用。降溫同時要留意整體保暖與失溫平衡。可連結:燒傷急救五步驟、組織熱傷、低體溫、傷口污染防護。",[24,26,29,31],{"term":25,"count":10},"失溫預防",{"term":27,"count":28},"燒傷急救沖脫泡蓋送",1,{"term":30,"count":28},"冷水而非冰水",{"term":32,"count":28},"冰水加重缺血",[34,38,43,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-108-2-medical-surgical-046","有關後天免疫之敘述，下列何者錯誤？",46,{"webId":39,"stem":40,"number":41,"year":42,"session":28},"nurse-109-1-medical-surgical-062","張先生，68 歲，罹患糖尿病、高血壓，冠心症長期服用降血糖藥物、抗凝血劑及高血壓藥物，但血壓仍維持在 150～170／90～110 mmHg。近日因血尿、下肢水腫、發燒而入院，住院期間病人不宜接受下列何項診斷性檢查？",62,109,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-109-2-medical-surgical-076","有關「臺灣急診檢傷與急迫度分級量表」（TTAS）的敘述，下列何者正確？",76,{"webId":48,"stem":49,"number":50,"year":51,"session":28},"nurse-111-1-medical-surgical-034","下列何者是心肌梗塞最常見且會導致死亡的併發症？",34,111,{"webId":53,"stem":54,"number":55,"year":56,"session":28},"nurse-112-1-medical-surgical-078","有關敗血症生理病理機轉之敘述，下列何者正確？①細菌感染引發腫瘤壞死因子活化產生微小血栓 ②微生物侵入人體造成微血管通透性增加、全身循環血量增加 ③全身代謝狀態升高造成細胞耗氧量增加，但組織血流灌注降低，產生代謝性酸中毒 ④因心臟受刺激出現血壓上升，可能引發尿量增加",78,112,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-113-2-medical-surgical-012","有關腔隙症候群的症狀，下列敘述何者錯誤？①失去尖鈍或兩點辨識力 ②患肢末梢脈搏減弱 ③微血管充填時間大於 3 秒 ④皮膚上出現出血斑點",12,113,"2026-09-04",1788510706554]