[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-110-2-fundamental-nursing-023":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":64},"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":12,"stem":13,"options":14,"answer":19,"answerNote":20,"images":21,"explanation":22,"explanationDeep":23,"topics":24,"freq":27},"nurse-110-2-基本護理學與護理行政-023","nurse-110-2-fundamental-nursing-023",110,2,23,"王先生身體外觀瘦弱，右小腿有一處 2×3 公分的傷口，左側偏癱無法行走，無法自行進食，有中度脫水情形。王先生的問題，下列何者應最優先處理？",{"A":15,"B":16,"C":17,"D":18},"皮膚完整性受損","活動功能障礙","體液容積缺失","營養少於身體需要","C",null,[],"本題考點為護理問題的優先順序判斷。考點在於依馬斯洛需求層級，維持生命的生理需求最優先；病人有中度脫水（體液容積缺失），會影響循環血量與電解質平衡，最直接威脅生命穩定，故最優先處理C。A皮膚完整性受損雖有傷口，但非立即致命。B活動功能障礙屬安全與功能層面，優先度較低。D營養少於身體需要影響長期復原，但非最急迫。故在四者中以體液容積缺失最優先介入。","優先順序判斷常用馬斯洛與ABC原則：危及生命的循環、呼吸、體液電解質問題優先於安全、功能與心理層面。中度脫水可致低血容、心搏過速與器官灌流不足。記憶：先救命（生理）、再安全、再功能。可連結：馬斯洛需求層級、體液電解質平衡、護理診斷排序。",[25,28,30,32],{"term":26,"count":27},"護理問題優先順序",4,{"term":17,"count":29},3,{"term":31,"count":11},"馬斯洛需求層級",{"term":33,"count":34},"脫水生理影響",1,[36,40,45,49,54,59],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-110-2-fundamental-nursing-024","陳女士，50 歲，罹患糖尿病多年，下肢現有 5×3×2 公分潰瘍性傷口，傷口分泌物惡臭有腐肉，入院進行傷口清創手術，其護理目標之訂定，下列何者最適當？",24,{"webId":41,"stem":42,"number":43,"year":44,"session":34},"nurse-111-1-fundamental-nursing-040","關於心搏過緩（bradycardia）的描述，下列何者正確？",40,111,{"webId":46,"stem":47,"number":48,"year":44,"session":11},"nurse-111-2-fundamental-nursing-054","依照衛生福利部公告之腦死判定準則，下列何者屬於腦死的認定標準？①低體溫昏迷 ②無腦幹反射 ③須經一次腦幹功能測試 ④無自行呼吸",54,{"webId":50,"stem":51,"number":52,"year":53,"session":29},"nurse-112-3-fundamental-nursing-012","病人的血液檢驗報告為鈉離子 138 mEq\u002FL、鉀離子 2.9 mEq\u002FL、氯離子 102 mEq\u002FL、鈣離子 4.8 mEq\u002FL，針對檢驗結果的判讀，下列何者正確？",12,112,{"webId":55,"stem":56,"number":57,"year":58,"session":34},"nurse-114-1-fundamental-nursing-016","病人因泌尿道感染，醫囑：Gentamycin ® 10 mg in N\u002FS 30 mL drip 30 min，有關使用精密輸液套管加藥的步驟，下列敘述何者錯誤？",16,114,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-115-2-fundamental-nursing-010","醫囑「Rinteron solution 1gtt. O.U. Q6h」及「Tetracycline oint. O.U. Q6h」，下列給藥的敘述何者錯誤？",10,115,"2026-09-04",1788510728222]