[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":63},"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-055","nurse-109-2-medical-surgical-055",109,2,55,"有關護理師給予氣切造口（tracheostomy）病人抽痰時，下列措施何者最重要？",{"A":14,"B":15,"C":16,"D":17},"執行氣切造口護理","聽診呼吸音","給予抗焦慮劑","評估血氧的變化","D",null,[],"本題考點是氣切造口病人抽痰時的護理重點。考點在於辨識抽痰過程會同時抽走氣道內氧氣、易造成低血氧與心律變化，故過程中最重要的是評估血氧（SpO₂）的變化以確保安全，選D。A執行氣切造口護理是抽痰後的清潔照護，非抽痰當下最重要。B聽診呼吸音可判斷是否需抽痰及成效，屬重要評估，但監測缺氧攸關生命更為優先。C給予抗焦慮劑並非抽痰的常規必要措施。抽痰最主要的立即風險是低血氧，故監測血氧變化最重要，選D。","抽痰安全原則：抽吸前後給予高濃度氧（pre-oxygenation）、單次抽吸不超過10–15秒、負壓維持在建議範圍（成人約100–150mmHg）、抽吸時邊退邊旋轉且不邊進邊抽，全程監測SpO₂與心律，出現血氧下降或心律不整立即停止並給氧。並發症：低血氧、心律不整、迷走神經刺激致心搏過緩、黏膜損傷、感染。記憶：「抽痰＝順便抽走氧氣，盯著血氧最要緊、十秒內收手」。",[24,27,29,31],{"term":25,"count":26},"氣切抽痰",1,{"term":28,"count":26},"抽痰致低血氧",{"term":30,"count":26},"SpO2監測",{"term":32,"count":26},"抽吸時間限制",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-109-2-medical-surgical-056","下列動脈血液氣體分析的報告，何者最能顯示慢性阻塞性肺疾病（COPD）病人的情況惡化？",56,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-110-1-medical-surgical-072","有關糖尿病性酮酸中毒（DKA）治療之敘述，下列何者正確？",72,110,{"webId":44,"stem":45,"number":46,"year":47,"session":26},"nurse-111-1-medical-surgical-006","有關頭部創傷之敘述，下列何者正確？",6,111,{"webId":49,"stem":50,"number":51,"year":52,"session":26},"nurse-112-1-medical-surgical-044","王同學騎機車不慎與汽車擦撞引發機車起火，右小腿外側有 15 公分 ×7.5 公分的皮膚受損，診斷為深二度燒傷。下列臨床表徵何者正確？①皮膚變紅無水泡 ②皮膚呈灰白色有水泡 ③劇烈疼痛感 ④汗腺及毛囊完整 ⑤表皮及真皮層受損",44,112,{"webId":54,"stem":55,"number":56,"year":57,"session":26},"nurse-113-1-medical-surgical-038","下列那些檢查前需要確認病人腎功能？①腎動脈攝影術 ②腎臟、輸尿管、膀胱X光檢查 ③腎臟超音波 ④逆行性腎盂攝影術 ⑤靜脈注射腎盂攝影術",38,113,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-114-2-medical-surgical-032","有關高血鈉之敘述，下列何者正確？①血鈉的濃度＞130 mEq\u002FL ②導因之一為醛固酮過多症導致 ③尿比重上升 ④指導低鈉飲食如蘇打餅乾、白麵包",32,114,"2026-09-04",1788510716794]