[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-1-medical-surgical-060":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"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":10},"nurse-110-1-內外科護理學-060","nurse-110-1-medical-surgical-060",110,1,60,"當慢性阻塞性肺疾病（COPD）病人出現下列何種評估結果時，護理師須優先採取因應措施？",{"A":14,"B":15,"C":16,"D":17},"杵狀指","白色濃痰","使用呼吸輔助肌","桶狀胸","C",null,[],"本題考點在於辨識慢性阻塞性肺疾病（COPD）病人惡化的優先警訊。使用呼吸輔助肌（如胸鎖乳突肌、肋間肌）代表呼吸做功增加、換氣代償吃緊，屬急性惡化與即將呼吸衰竭的警示，護理師須優先因應，故選C。選項A杵狀指屬慢性缺氧的長期表現，反映病程但非急性緊急。選項B白色濃痰若無合併發燒、痰量或痰色改變，多屬慢性穩定表現。選項D桶狀胸是長期肺部過度充氣造成的結構性慢性變化，無急迫性。三者屬慢性表徵，唯呼吸輔助肌使用提示當下呼吸窘迫，須即時處置。","COPD慢性徵象（杵狀指、桶狀胸、慢性咳痰）反映長期病程，護理判斷須把「急性惡化警訊」拉到最前面：呼吸輔助肌使用、三凹徵象、呼吸速率上升、意識改變、發紺、SpO₂驟降皆屬紅旗。呼吸輔助肌動員意味潮氣量靠正常橫膈已不足，是代償轉向失代償的臨界。惡化評估可搭配ABG看CO₂滯留（第二型呼吸衰竭）與pH。臨床考點在分辨「結構慢性表現」與「當下呼吸做功」。可連結：三凹徵象、第二型呼吸衰竭、呼吸做功、急性惡化。",[24,26,28,30],{"term":25,"count":10},"COPD急性惡化",{"term":27,"count":10},"呼吸輔助肌",{"term":29,"count":10},"呼吸做功",{"term":31,"count":10},"優先處置判斷",[33,37,42,47,52,58],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-110-1-medical-surgical-061","有關血液透析（HD）與持續可攜帶式腹膜透析（CAPD）治療的敘述，下列何者錯誤？",61,{"webId":38,"stem":39,"number":40,"year":9,"session":41},"nurse-110-2-medical-surgical-077","何處骨折最適合使用八字繃帶法進行固定？",77,2,{"webId":43,"stem":44,"number":45,"year":46,"session":41},"nurse-111-2-medical-surgical-011","有關肝癌的敘述，下列何者正確？",11,111,{"webId":48,"stem":49,"number":50,"year":51,"session":41},"nurse-112-2-medical-surgical-049","有關免疫球蛋白特性之敘述，下列何者正確？",49,112,{"webId":53,"stem":54,"number":55,"year":56,"session":57},"nurse-113-3-medical-surgical-023","有關體液容積過量之檢驗結果，下列敘述何者正確？①血比容下降 ②血尿素氮下降 ③血漿滲透壓上升 ④血鈉上升",23,113,3,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-115-1-medical-surgical-017","有關血栓性靜脈炎之評估與照護原則，下列敘述何者錯誤？",17,115,"2026-09-04",1788510721348]