[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-035":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":26},"nurse-109-2-內外科護理學-035","nurse-109-2-medical-surgical-035",109,2,35,"王先生入院接受心導管檢查，此次檢查穿刺左側橈動脈，下列護理處置何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"教導病人加壓傷口至少 2 小時，並觀察有無出血","檢查後，第 1 小時應每 15 分鐘測量雙手血壓，並做比較","以 6P（pain、pallor、pulselessness、poikilothermia、paralysis、paresthesia）評估病人雙手末梢，並做比較","教導病人出院後，左手禁提重物","B",null,[],"本題考點是經橈動脈（radial approach）心導管術後的護理，並找出「錯誤」項。考點在於辨識穿刺側肢體應盡量避免加壓與影響循環的操作：在剛穿刺加壓止血的左手上反覆量血壓，壓脈帶充氣會壓迫傷口、增加出血或血腫風險，也影響末梢灌流，故B屬錯誤處置。A正確，橈動脈屬淺表動脈，術後須加壓傷口並觀察出血。C正確，以6P（疼痛、蒼白、無脈、溫度異常、麻痺、感覺異常）評估雙手末梢循環並比較是標準做法。D正確，穿刺側手術後短期禁提重物，以免傷口出血或假性動脈瘤。因此唯一錯誤是B在穿刺側加壓測血壓比較。","橈動脈途徑相較股動脈途徑（femoral）出血少、可早期下床，但橈動脈細小、痙攣與閉塞風險較高，術後常用充氣式止血帶漸進洩壓。護理原則：量血壓、抽血、點滴皆避開穿刺側手臂。評估Allen test確認尺動脈側枝循環是術前重點。6P是急性動脈阻塞（compartment\u002Fischemia）的評估指標。記憶：「穿刺那隻手，別綁別測別提重」。",[24,27,29,31],{"term":25,"count":26},"橈動脈途徑心導管",1,{"term":28,"count":26},"6P評估",{"term":30,"count":26},"穿刺側肢體照護",{"term":32,"count":26},"假性動脈瘤預防",[34,38,43,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-109-2-medical-surgical-036","依據安阿伯（Ann Arbor）臨床分期系統，下列何者屬於何杰金氏淋巴瘤第Ⅱ期？",36,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-110-1-medical-surgical-052","車禍外傷病人出現胸部右側聽不到呼吸音，且氣管向左側偏移，下列處置何者最適當？",52,110,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-110-2-medical-surgical-066","引起代謝性酸中毒的原因，下列何者正確？①延腦異常 ②急性腎衰竭 ③肺擴張不全 ④血糖過高",66,{"webId":48,"stem":49,"number":50,"year":51,"session":26},"nurse-112-1-medical-surgical-024","有關喉癌病人接受全喉切除術的敘述，下列何者正確？",24,112,{"webId":53,"stem":54,"number":55,"year":56,"session":26},"nurse-113-1-medical-surgical-018","下列何者為冠狀動脈性心臟病人服用Aspirin之主要目的？",18,113,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-114-2-medical-surgical-012","有關病人因左膝關節退化性關節炎接受全膝關節置換術之術後照護，下列何者最不適當？",12,114,"2026-09-04",1788510716612]