[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-109-1-fundamental-nursing-038":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":65},"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-109-1-基本護理學與護理行政-038","nurse-109-1-fundamental-nursing-038",109,1,38,"根據下列四位住院病人之生命徵象測量結果，何者應最優先處理？",{"A":15,"B":16,"C":17,"D":18},"80 歲女性，肺炎，RR 27 次\u002F分，SpO 2 80%","50 歲男性，小腿骨折，BP 160\u002F80 mmHg、PR 80 次\u002F分","60 歲男性，糖尿病足合併蜂窩組織炎，BT 38.2℃、PR 96 次\u002F分","75 歲女性，3 天前右側乳房切除，BP 146\u002F86 mmHg、RR 22 次\u002F分","A",null,[],"本題考點為依ABC（氣道、呼吸、循環）原則與生命徵象異常程度排序照護優先順序。A之80歲肺炎病人呼吸27次\u002F分、血氧飽和度僅80%，遠低於正常的95%以上，屬急性缺氧、危及生命的呼吸窘迫，依ABC原則呼吸問題最優先，故選A。B小腿骨折血壓160\u002F80雖偏高但生命徵象穩定。C糖尿病足合併蜂窩組織炎發燒38.2度屬感染但非立即致命。D乳房切除術後第三天血壓、呼吸僅輕度偏高，皆非最緊急。故A應最優先處理。","SpO₂正常在95%以上，低於90%即明顯低血氧，80%屬嚴重缺氧，對應PaO₂僅約45至50 mmHg（依血氧解離曲線）。臨床檢傷與病情惡化辨識均遵循ABC，先確保Airway、Breathing、Circulation。缺氧數分鐘即可致腦損傷，故永遠優先於單純血壓升高或發燒。",[25,28,30,32],{"term":26,"count":27},"ABC原則",5,{"term":29,"count":11},"血氧飽和度正常值",{"term":31,"count":11},"低血氧",{"term":33,"count":11},"病情優先順序",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-109-1-fundamental-nursing-039","病人的呼吸開始時短而淺，之後漸漸加深，然後又逐漸下降，直至呼吸暫停或完全停止，呈週期性出現，此種呼吸型態稱為？",39,{"webId":40,"stem":41,"number":42,"year":10,"session":43},"nurse-109-2-fundamental-nursing-055","有關臨終病人生理變化之敘述，下列何者錯誤？",55,2,{"webId":45,"stem":46,"number":47,"year":48,"session":11},"nurse-110-1-fundamental-nursing-069","使用多項護理人力的彈性運用策略，以解決護理人力短缺問題，下列何者屬於「數量彈性」？",69,110,{"webId":50,"stem":51,"number":52,"year":53,"session":43},"nurse-111-2-fundamental-nursing-027","有關不宜使用熱療法的高危險情況與原因的理論依據，下列敘述何者正確？",27,111,{"webId":55,"stem":56,"number":57,"year":58,"session":43},"nurse-112-2-fundamental-nursing-071","有關全責護理模式（primary nursing care model）之敘述，下列何者正確？",71,112,{"webId":60,"stem":61,"number":62,"year":63,"session":64},"nurse-113-3-fundamental-nursing-035","人死亡後所產生的隨意肌部分的屍僵變化，一般從那個部位最先發生？",35,113,3,"2026-09-04",1788510711955]