[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-110-2-fundamental-nursing-002":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":65},"基本護理學與護理行政","fundamental-nursing","基本護理學(包括護理原理、護理技術)與護理行政",{"id":8,"webId":9,"year":10,"session":11,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-110-2-基本護理學與護理行政-002","nurse-110-2-fundamental-nursing-002",110,2,"下列何種情況出現時只需要記錄，不需要報告？",{"A":14,"B":15,"C":16,"D":17},"體溫 37.6℃的病人經衛教後能多喝水","糖尿病病人足部潰瘍在換藥後發現傷口周圍有明顯的泛紅情形","姿位性低血壓的病人在下床時跌倒","躁症病患與其他病人在病室發生口角衝突","A",null,[],"本題考點為護理紀錄與通報（報告）時機的判斷，屬區辨題。考點在於辨識僅需記錄、無須立即報告者，應是病情穩定、屬常規護理處置且無安全或病情變化風險的情況；選項 A 病人體溫 37.6℃、經衛教後能增加水分攝取，屬輕微且已妥適處理的常規事件，故選 A。B 傷口周圍明顯泛紅提示可能感染惡化、C 病人跌倒屬不良事件、D 病室內衝突涉及安全與精神狀態，三者皆須依規定通報並記錄，非僅記錄即可。","臨床紀錄與通報的分界原則：凡涉及病情顯著變化、不良事件（跌倒、給藥錯誤、管路滑脫）、感染徵象惡化、安全或衝突事件，皆須及時向負責醫護通報並留存紀錄，以利即時介入與後續品質改善；而輕微、已處理且無風險升高的常規情形，完整記錄即可。跌倒即使無明顯受傷仍屬須通報之異常事件。記憶法：有變化、有風險、有事故就要報，穩定常規只需記。可連結概念：異常事件通報（incident report）、病人安全、護理紀錄的完整性與時效性。",[24,27,29,32,34],{"term":25,"count":26},"病人安全",17,{"term":28,"count":11},"異常事件通報",{"term":30,"count":31},"護理紀錄與通報時機",1,{"term":33,"count":31},"病情變化判斷",{"term":35,"count":31},"常規處置紀錄",[37,41,46,50,55,60],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-110-2-fundamental-nursing-003","為四肢水腫嚴重病人執行盤尼西林皮膚試驗時，下列何者為最適合的注射部位？",3,{"webId":42,"stem":43,"number":44,"year":45,"session":31},"nurse-111-1-fundamental-nursing-019","高先生為第 2 型糖尿病病人，醫囑「RI 8 I.U. S.C. t.i.d. a.c.」，下列敘述何者錯誤？",19,111,{"webId":47,"stem":48,"number":49,"year":45,"session":11},"nurse-111-2-fundamental-nursing-033","護理師為老年病人執行背部護理時，下列何者錯誤？",33,{"webId":51,"stem":52,"number":53,"year":54,"session":11},"nurse-112-2-fundamental-nursing-071","有關全責護理模式（primary nursing care model）之敘述，下列何者正確？",71,112,{"webId":56,"stem":57,"number":58,"year":59,"session":40},"nurse-113-3-fundamental-nursing-045","有關組織中分權的特性，下列何者正確？",45,113,{"webId":61,"stem":62,"number":63,"year":64,"session":31},"nurse-115-1-fundamental-nursing-039","決策者預測不利後果情況下，從眾多方案中選擇危害最小的方案，此種決策策略是屬於下列何者？",39,115,"2026-09-04",1788510728044]