[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-110-2-medical-surgical-053":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":65},"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-110-2-內外科護理學-053","nurse-110-2-medical-surgical-053",110,2,53,"接受胸腔放液後的病人，下列何者最需緊急處理？",{"A":14,"B":15,"C":16,"D":17},"主訴疼痛為 5 分（以 0～10 分的疼痛量表作評估）","周邊血氧濃度為 88%","血壓 156\u002F88 mmHg","平躺時呼吸次數為 24 次／分","B",null,[],"本題考點在胸腔放液(thoracentesis)後的併發症辨識與危急優先順序。放液後最需警覺的併發症是氣胸,周邊血氧濃度88%代表明顯低血氧,提示可能發生氣胸或肺擴張不全而危及氧合,屬最需緊急處理者,故選B。疼痛5分屬中度、可評估後給藥但非立即危急;血壓156\u002F88僅輕度偏高;平躺呼吸24次每分雖略快但尚可觀察。相較之下血氧下降對生命威脅最直接,故為答案。","胸腔放液常見併發症:氣胸(針刺傷肺)、出血、複張性肺水腫(單次抽液過多)、感染。監測重點在放液後的呼吸型態、血氧與有無突發胸痛或呼吸困難。判斷急迫性用ABC原則:氣道與呼吸(氧合)優先於循環與疼痛,故SpO₂ 88%排序最前。可連結血氧正常應大於等於95%,88%對應PaO₂約55 mmHg已達呼吸衰竭邊緣。",[24,27,29,31,33],{"term":25,"count":26},"胸腔放液",1,{"term":28,"count":26},"氣胸併發症",{"term":30,"count":26},"血氧濃度",{"term":32,"count":26},"ABC優先順序",{"term":34,"count":26},"低血氧",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-110-2-medical-surgical-054","下列何者不是造成肺泡通氣不足而導致呼吸衰竭的原因？",54,{"webId":41,"stem":42,"number":43,"year":44,"session":26},"nurse-111-1-medical-surgical-070","有關抗利尿激素分泌不當症候群（SIADH）之臨床表徵，下列何者錯誤？",70,111,{"webId":46,"stem":47,"number":48,"year":49,"session":26},"nurse-112-1-medical-surgical-004","有關腦腫瘤病人術後發生尿崩症，下列敘述何者正確？",4,112,{"webId":51,"stem":52,"number":53,"year":49,"session":54},"nurse-112-3-medical-surgical-042","有關腎臟移植發生排斥時的主要處置，下列敘述何者錯誤？",42,3,{"webId":56,"stem":57,"number":58,"year":59,"session":26},"nurse-114-1-medical-surgical-046","有關糖尿病足病人運動時鞋襪選擇之建議，下列何者錯誤？",46,114,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-115-2-medical-surgical-040","有關接受膀胱鏡檢查病人的護理指導，下列何者不適當？",40,115,"2026-09-04",1788510729294]