[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-1-medical-surgical-058":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"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-110-1-內外科護理學-058","nurse-110-1-medical-surgical-058",110,1,58,"有關促進急性呼吸窘迫症候群（ARDS）病人有效呼吸道清除的護理措施，下列何者正確？",{"A":14,"B":15,"C":16,"D":17},"每 2 小時給氧","每 4 小時翻身","給予鎮靜劑以促進休息","若咳嗽無效，可進行抽痰","D",null,[],"本題考點在於急性呼吸窘迫症候群（ARDS）維持呼吸道清除的護理原則。ARDS病人常有濃痰堆積且咳嗽力量不足，當自咳無效無法有效清除分泌物時，應執行抽痰以維持呼吸道通暢，故選D。選項A錯在給氧措施改善的是氧合而非呼吸道清除，且應依血氧持續而非固定每2小時。選項B錯在翻身拍背應更頻繁（約每2小時）以促進痰液引流，每4小時不足。選項C錯在鎮靜劑會抑制咳嗽反射與呼吸驅動，反而阻礙分泌物清除，非清除呼吸道的措施。抽痰是直接清除氣道分泌物的有效方式。","ARDS病生理為肺泡微血管膜受損、通透性增加，造成非心因性肺水腫、肺泡塌陷與嚴重低血氧（P\u002FF ratio下降）。護理診斷「呼吸道清除功能失效」的對策層次：先鼓勵深呼吸咳嗽→翻身拍背與姿位引流→濕化痰液→自咳無效才抽痰。抽痰須留意每次≤10–15秒、先給氧避免低血氧。ARDS常需俯臥擺位改善通氣灌流比與低潮氣容積肺保護策略。可連結：肺保護通氣、P\u002FF ratio、姿位引流、俯臥治療。",[24,27,29,32],{"term":25,"count":26},"呼吸道清除功能失效",3,{"term":28,"count":26},"姿位引流",{"term":30,"count":31},"ARDS",2,{"term":33,"count":10},"抽痰時機",[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-110-1-medical-surgical-059","病人的動脈血氧分析結果 PaO 2 值為 50 mmHg，此病人 PaO 2 的判讀及處置，下列何者正確？",59,{"webId":40,"stem":41,"number":42,"year":9,"session":31},"nurse-110-2-medical-surgical-075","有關糖尿病視網膜病變的敘述，下列何者錯誤？",75,{"webId":44,"stem":45,"number":46,"year":47,"session":31},"nurse-111-2-medical-surgical-009","有關發炎性腸道疾病的敘述，下列何者正確？",9,111,{"webId":49,"stem":50,"number":51,"year":52,"session":31},"nurse-112-2-medical-surgical-047","下列何者屬於主動性後天免疫？",47,112,{"webId":54,"stem":55,"number":56,"year":57,"session":26},"nurse-113-3-medical-surgical-021","有關化學藥品 vincristine（Oncovin ® ）輸注之藥物準備過程，下列何者不適當？",21,113,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-115-1-medical-surgical-015","有關病人使用青光眼用藥Timolol的護理指導，下列何者錯誤？",15,115,"2026-09-04",1788510721340]