[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-007":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":36,"lastmod":66},"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":26},"nurse-109-2-內外科護理學-007","nurse-109-2-medical-surgical-007",109,2,7,"王小姐進行經蝶骨腦下垂體切除術，術後發現鼻部有水樣液體流出之護理措施，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"利用尿糖試紙檢視分泌物性質","將病人的床頭抬高 30 度","用無菌的抽吸管吸乾淨","用無菌棉球塞住鼻孔","A",null,[],"本題考點在於經蝶骨腦下垂體切除術後辨識腦脊髓液滲漏的護理措施。手術經鼻蝶入路可能傷及硬腦膜，若鼻部流出水樣液體須先判斷是否為腦脊髓液；腦脊髓液含葡萄糖，故以尿糖試紙檢測分泌物，若呈葡萄糖陽性即提示腦脊髓液漏，選 A。B 抬高床頭 30 度雖為術後常規擺位，但無助於「判斷分泌物性質」，非本題所問重點。C 用抽吸管吸取會增加逆行性感染與顱內壓變化風險，屬禁忌。D 以棉球塞鼻孔會阻礙引流、增加感染與壓力，亦不當。故正確措施為以尿糖試紙檢視分泌物。","經蝶骨手術後鼻漏鑑別是關鍵考點：腦脊髓液葡萄糖濃度高，尿糖試紙或葡萄糖定量可初步篩檢；更專一的是檢測 β₂-transferrin。臨床另有「暈輪徵象（halo\u002Fring sign）」——滴在紗布上血液中央、外圈為透明環，提示混有腦脊髓液。護理原則：避免擤鼻、咳嗽、彎腰用力等增加顱內壓與逆流的動作，並衛教勿自行填塞鼻孔，以降低腦膜炎風險。抬高床頭有助引流與降壓，但不能用來「鑑別」液體來源。",[24,27,29,32,34],{"term":25,"count":26},"腦脊髓液漏",4,{"term":28,"count":10},"經蝶骨腦下垂體切除術",{"term":30,"count":31},"尿糖試紙",1,{"term":33,"count":31},"暈輪徵象",{"term":35,"count":31},"腦膜炎預防",[37,41,46,50,55,61],{"webId":38,"stem":39,"number":40,"year":9,"session":10},"nurse-109-2-medical-surgical-008","陳先生早上騎機車出門上班時，於十字路口與計程車擦撞倒地，同時頭部撞到地面，當時意識清楚但有多處擦傷及撕裂傷，由救護車送至急診室，當醫師正在縫合傷口時，陳先生突然喪失意識，其最大可能為下列何種頭部創傷？",8,{"webId":42,"stem":43,"number":44,"year":45,"session":31},"nurse-110-1-medical-surgical-024","因呼吸衰竭而血中二氧化碳分壓（PaCO 2 ）過高時，下列症狀何者最可能立即危及生命？",24,110,{"webId":47,"stem":48,"number":49,"year":45,"session":10},"nurse-110-2-medical-surgical-038","有關何杰金氏淋巴瘤的敘述，下列何者錯誤？",38,{"webId":51,"stem":52,"number":53,"year":54,"session":10},"nurse-111-2-medical-surgical-076","有關骨折病人到院前急救處理原則，下列何者為最優先的處置？",76,111,{"webId":56,"stem":57,"number":58,"year":59,"session":60},"nurse-112-3-medical-surgical-040","有關腎臟功能血液檢查，下列敘述何者正確？",40,112,3,{"webId":62,"stem":63,"number":64,"year":65,"session":31},"nurse-114-1-medical-surgical-034","下列何者不屬於動脈血液氣體分析（arterial blood gas analysis）可以直接偵測之項目？",34,114,"2026-09-04",1788510716307]