[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-109-2-medical-surgical-064":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":10},"nurse-109-2-內外科護理學-064","nurse-109-2-medical-surgical-064",109,2,64,"關於膀胱癌接受膀胱切除及輸尿管造瘻術術後病人之護理措施，下列何者不適當？",{"A":14,"B":15,"C":16,"D":17},"教導病人及照顧者觀察造瘻口之顏色、大小、形狀","集尿袋尿液達 80%才需排空","鼓勵每日攝取液體 2,000～3,000 mL","鼓勵病人表達感受，傾聽病人給予心理支持","B",null,[],"本題考點是輸尿管造瘻（urostomy）術後集尿袋的排空時機。造瘻口尿液持續滴流，集尿袋若裝到太滿，重量會拉扯造瘻口周圍皮膚、增加滲漏與皮膚破損風險，臨床原則是尿液達集尿袋容量約三分之一至二分之一即排空，故選項B「達80%才排空」不適當，為正解。選項A觀察造瘻口顏色、大小、形狀以早期發現缺血或狹窄，屬正確措施；選項C每日攝取2,000～3,000 mL水分可稀釋尿液、預防結石與泌尿道感染，正確；選項D傾聽並給予心理支持，協助病人適應改變後的身體心像，正確。","造瘻口護理的兩大主軸是皮膚完整性與心理適應。集尿袋過滿除拉扯滲漏外，也易讓尿液逆流刺激造瘻口。正常造瘻口應呈紅潤濕潤、稍突出；若轉暗紫或發黑代表血流受阻須警覺。回教學重點：迴腸導管尿液會含少量腸黏液屬正常，勿誤判為感染。充足水分沖刷是預防泌尿道感染與結石的第一線；身體心像重建則需鼓勵病人表達、及早參與自我照顧與造瘻口清潔，是長期成功的關鍵。",[24,26,29,31],{"term":25,"count":10},"身體心像",{"term":27,"count":28},"輸尿管造瘻術",1,{"term":30,"count":28},"集尿袋排空時機",{"term":32,"count":28},"造瘻口皮膚完整性",[34,38,42,47,52,57],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-109-2-medical-surgical-065","腎臟肌酸酐清除率（CCr）正常值範圍是多少 mL\u002Fmin？",65,{"webId":39,"stem":40,"number":28,"year":41,"session":10},"nurse-110-2-medical-surgical-001","有關前窩顱底骨折的敘述，下列何者正確？",110,{"webId":43,"stem":44,"number":45,"year":46,"session":28},"nurse-111-1-medical-surgical-015","有關癌症病人貧血問題之敘述，下列何者錯誤？",15,111,{"webId":48,"stem":49,"number":50,"year":51,"session":28},"nurse-112-1-medical-surgical-053","全球慢性阻塞性肺疾病倡議組織（Global Initiative for Chronic Obstructive Lung Disease, GOLD）將 COPD 嚴重度分為 GOLD 1～4 級，下列何者為分級依據？",53,112,{"webId":53,"stem":54,"number":55,"year":56,"session":28},"nurse-113-1-medical-surgical-047","有關休克病人體溫下降之護理措施，下列何者正確？",47,113,{"webId":58,"stem":59,"number":60,"year":61,"session":10},"nurse-114-2-medical-surgical-041","高小姐的動脈血液氣體分析結果為 pH 7.48、PaCO 2 48 mmHg、HCO 3- 30 mmHg、PaO 2 92 mmHg，根據以上數值，判讀結果下列何者正確？",41,114,"2026-09-04",1788510716894]