[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-111-1-fundamental-nursing-053":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"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-111-1-基本護理學與護理行政-053","nurse-111-1-fundamental-nursing-053",111,1,53,"王先生因氣喘發作而急診入院，剛轉入病房，可聽見呼吸喘鳴音（wheezing），首要的入院護理措施為何？",{"A":15,"B":16,"C":17,"D":18},"病史詢問","說明痰液檢體收集方法","病室環境介紹","抬高床頭並測量生命徵象","D",null,[],"本題考點在於氣喘急性發作的護理措施優先順序,判斷依據是 ABC(呼吸道、呼吸、循環)與馬斯洛需求層次中生理需求優先的原則。病人已聽見哮鳴音,代表下呼吸道支氣管痙攣、通氣受阻,此時維持呼吸道通暢與監測生理狀態的重要性凌駕於一切,選 D:抬高床頭採半坐臥可增加胸腔擴張、降低橫膈上抬阻力以改善通氣,測量生命徵象可掌握呼吸速率與血氧變化,兩者皆屬立即性的生理需求。A 病史詢問屬入院資料蒐集,可延後且會加重喘息中病人負擔;B 說明痰液檢體收集是後續診斷步驟,非急性期首要;C 病室環境介紹屬心理社會層次,在生命徵象未穩定前不具優先性。","氣喘發作的核心病生理是支氣管平滑肌痙攣、黏膜水腫與痰液增加造成呼氣性呼吸困難,故聽診出現高調哮鳴音(wheezing)。半坐臥(High-Fowler's)可讓腹部器官下移、橫膈下降,增加潮氣容積並讓輔助呼吸肌得以運作。記憶上可套用「先救命再蒐集資料」:凡選項出現維持呼吸道\u002F測量生命徵象,幾乎都優先於問診、衛教、環境介紹。可延伸連結氧合評估(SpO₂)、噘嘴呼吸與支氣管擴張劑的使用時機。",[25,28,30,32],{"term":26,"count":27},"馬斯洛需求層次",7,{"term":29,"count":11},"ABC 呼吸道優先原則",{"term":31,"count":11},"半坐臥改善通氣",{"term":33,"count":11},"氣喘哮鳴音",[35,39,44,49,54,60],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-111-1-fundamental-nursing-054","有關臨終照護的敘述，下列何者錯誤？",54,{"webId":40,"stem":41,"number":42,"year":10,"session":43},"nurse-111-2-fundamental-nursing-070","為擴大護理師視野，採水平方向改變工作職務，職稱不變，屬於下列何種工作設計方式？",70,2,{"webId":45,"stem":46,"number":47,"year":48,"session":43},"nurse-112-2-fundamental-nursing-004","醫院中最常使用戊乙醛（Cidex）消毒劑來消毒那些物品或設備？",4,112,{"webId":50,"stem":51,"number":52,"year":53,"session":43},"nurse-113-2-fundamental-nursing-022","記錄導尿管留置病人的輸出入量時，發現 3 小時中尿袋內的尿量為零，應先執行下列何項處置？",22,113,{"webId":55,"stem":56,"number":57,"year":58,"session":59},"nurse-114-3-fundamental-nursing-026","測量呼吸時注意事項，下列何者最不適當？",26,114,3,{"webId":61,"stem":62,"number":42,"year":63,"session":11},"nurse-106-1-fundamental-nursing-070","以危機管理策略而言，醫學中心應採取下列何項較為適宜？",106,"2026-09-04",1788510733939]