[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-109-2-fundamental-nursing-039":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":32,"lastmod":61},"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-109-2-基本護理學與護理行政-039","nurse-109-2-fundamental-nursing-039",109,2,39,"一位心房纖維震顫病史的病人，其橈動脈 52 次／分鐘、搏動規律，病人無感到頭暈及疲倦，為了確認病人是否出現脈搏短絀的問題，下列何者為最適當之立即性處置？",{"A":15,"B":16,"C":17,"D":18},"重複測量雙側橈動脈","施作 12 導程心電圖","測量心尖脈搏動次數","評估足背動脈脈搏","C",null,[],"本題考點為脈搏短絀（pulse deficit）的評估方法。脈搏短絀指心尖脈與橈動脈脈搏數不一致（心尖大於橈脈），常見於心房纖維顫動，因部分心室收縮太弱無法把血打到橈動脈。要確認是否有脈搏短絀，最適當的立即處置是測量心尖脈搏動次數，與橈脈相比即可得差值，故選C（標準需兩人同時聽診心尖與觸診橈脈各一分鐘）。選項A重複測雙側橈動脈無法反映心尖搏動；選項B十二導程心電圖是診斷心律而非計算脈搏短絀的即時方法；選項D足背動脈評估周邊灌流，與脈搏短絀無關。","脈搏短絀等於心尖脈減橈脈（正值代表有短絀），需兩人同時、同一分鐘測量。機轉：心律不整（尤其心房纖維顫動）時，部分心室收縮太弱，雖有心跳（心尖聽得到）卻無法把足量血打到周邊（橈脈摸不到），形成落差，反映心室輸出效率不佳。本題橈脈52且規律，懷疑有漏搏，故先測心尖脈對照確認。",[25,27,30],{"term":26,"count":11},"心房纖維顫動",{"term":28,"count":29},"脈搏短絀 pulse deficit",1,{"term":31,"count":29},"心尖脈與橈脈差值",[33,37,42,46,51,56],{"webId":34,"stem":35,"number":36,"year":10,"session":11},"nurse-109-2-fundamental-nursing-040","一般成人的大腿血壓測量方式與結果之敘述，下列何者正確？",40,{"webId":38,"stem":39,"number":40,"year":41,"session":29},"nurse-110-1-fundamental-nursing-056","趙先生 68 歲，意識清楚，診斷肝硬化合併食道靜脈曲張，血小板：22,000\u002FμL，痰乾且量少，因病人發燒寒顫，醫師開立收集痰液培養（sputum culture）之醫囑，護理人員應如何執行最為適當？",56,110,{"webId":43,"stem":44,"number":45,"year":41,"session":11},"nurse-110-2-fundamental-nursing-070","有關國家辦理「護理師」考試的目的，下列何者錯誤？",70,{"webId":47,"stem":48,"number":49,"year":50,"session":29},"nurse-112-1-fundamental-nursing-028","接受會陰切開術的產後婦女採坐浴，使用的溶液及其作用之敘述，下列何者正確？",28,112,{"webId":52,"stem":53,"number":54,"year":55,"session":29},"nurse-113-1-fundamental-nursing-022","病人配戴橡膠製成的活動假牙，有關假牙的清潔與使用，下列敘述何者正確？",22,113,{"webId":57,"stem":58,"number":59,"year":60,"session":11},"nurse-114-2-fundamental-nursing-016","病人打籃球時跌倒，右側足踝處扭傷並有出血、擦傷。急診 X 光確定沒有骨折，可返家休養。離院前的護理指導內容，下列何者最適當？",16,114,"2026-09-04",1788510715822]