[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-1-fundamental-nursing-009":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":33,"lastmod":62},"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-111-1-基本護理學與護理行政-009","nurse-111-1-fundamental-nursing-009",111,1,9,"護理人員執行治療後於紀錄中寫下：「10：00 協助病人翻身，發現腳跟破皮傷口，給予傷口換藥」，此護理紀錄未遵守下列何項原則？",{"A":15,"B":16,"C":17,"D":18},"準確性","扼要性","時效性","組織性","A",null,[],"本題考點在於護理紀錄的書寫原則。紀錄「腳跟破皮傷口」僅描述部位與現象,卻未載明傷口的確切大小、深度、顏色、分泌物等可量化客觀資料,缺乏具體精確的描述,違反「準確性（accuracy）」原則,故A為本題答案。時效性（C）指即時記錄,此處有標明10:00尚符合;扼要性（B）指簡明,本紀錄並不冗長;組織性（D）指依邏輯順序記載,此處敘述順序合理。最欠缺者為準確、具體的傷口描述。","護理紀錄六大原則:準確性(客觀、具體、可量化)、完整性、時效性(即時)、扼要性、組織性(合邏輯順序)、合法性(據實不塗改)。本題『破皮傷口』屬含糊描述,正確應記錄如『右腳跟2×3公分表皮缺損,基底粉紅、無滲液』。口訣:傷口紀錄要『量測有數據、描述可重現』。準確性不足是最常見的紀錄缺失。",[25,28,29,31],{"term":26,"count":27},"護理紀錄原則",4,{"term":15,"count":11},{"term":30,"count":11},"客觀具體描述",{"term":32,"count":11},"傷口記錄",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":10,"session":11},"nurse-111-1-fundamental-nursing-010","醫囑 Demeral 10 mg I.V. drip St.之含意，下列敘述何者正確？",10,{"webId":39,"stem":40,"number":41,"year":10,"session":42},"nurse-111-2-fundamental-nursing-026","有關常見的熱療法方式與目的之敘述，下列何者錯誤？",26,2,{"webId":44,"stem":45,"number":46,"year":47,"session":11},"nurse-112-1-fundamental-nursing-040","楊先生為慢性腎臟疾病病人，其飲食下列何者最為適宜？",40,112,{"webId":49,"stem":50,"number":51,"year":52,"session":11},"nurse-113-1-fundamental-nursing-028","有關營養素的敘述，下列何者正確？",28,113,{"webId":54,"stem":55,"number":56,"year":57,"session":42},"nurse-114-2-fundamental-nursing-032","有關出院計畫的敘述，下列何者正確？①以病人為中心來制定計畫內容，以確保持續性照護 ②於醫師開立出院醫囑當天開始執行 ③需避免病人或家屬直接執行傷口照護，以防再度感染 ④由病人、照護者、醫師、護理師及其他醫療團隊共同擬訂",32,114,{"webId":59,"stem":60,"number":41,"year":61,"session":11},"nurse-106-1-fundamental-nursing-026","有關睡眠的敘述，下列何者正確？①快速動眼期的腦波圖呈現 β 波，很容易被叫醒 ②非快速動眼期第三期的腦波圖呈現 δ 波，呼吸速率及血壓下降 ③非快速動眼期第二期的腦波圖呈現θ波，容易被叫醒 ④非快速動眼期第四期的腦波圖呈現 δ 波，可能出現尿床及磨牙 ⑤當睡眠中斷時，必須從快速動眼期開始入睡",106,"2026-09-04",1788510733498]