[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-1-maternal-pediatric-061":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":62},"產兒科護理學","maternal-pediatric",{"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":10},"nurse-111-1-產兒科護理學-061","nurse-111-1-maternal-pediatric-061",111,1,61,"小凱，5 歲，入院診斷為右下肺葉肺炎，急性期發生呼吸窘迫症狀，下列護理措施何者較不適當？",{"A":14,"B":15,"C":16,"D":17},"維持補充體液，且監測及記錄尿量","維持組織氧合，給予氧氣、擺位、通氣及抽吸","預防感染，並治療潛在疾病","協助採左側臥，以緩解疼痛","D",null,[],"本題考點是右下肺葉肺炎併急性呼吸窘迫幼兒的護理措施,屬選『較不適當』題。A維持體液並監測尿量、B維持組織氧合(給氧、擺位、通氣、抽吸)、C預防感染並治療潛在疾病,皆為肺炎合併呼吸窘迫的標準措施,正確。D『協助採左側臥以緩解疼痛』最不適當:急性呼吸窘迫期的首要目標是維持氧合,而非以擺位緩解疼痛;且若為緩解患側(右側)不適,理應讓患側在下以夾板固定,採左側臥並不能緩解右側疼痛,理由與目的皆不相稱,故選D。","肺炎合併呼吸窘迫的護理優先序為ABC與氧合:確保呼吸道通暢、給氧、必要時擺位與抽吸,並補充體液、防治感染。擺位在成人多採『好肺在下(good lung down)』改善通氣灌流,但在嬰幼兒因胸廓與肺順應性不同,此原則不一定適用,故不會單純為『緩解疼痛』而固定採某側臥。本題D的破綻有二:一是把非緊要的『緩解疼痛』放到呼吸窘迫的處置中;二是左側臥對右側病灶疼痛並無夾板止痛效果,方向與目的均不合,屬設計來凸顯『分不清處置優先順序』的干擾選項。",[24,26,28,30],{"term":25,"count":10},"肺炎併呼吸窘迫護理優先序",{"term":27,"count":10},"維持氧合",{"term":29,"count":10},"兒童擺位原則",{"term":31,"count":10},"護理措施與目的相稱性",[33,37,42,47,52,58],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-111-1-maternal-pediatric-062","小佩，3 歲，因長期出現扁桃腺發炎，此次住院欲進行扁桃腺切除手術，有關手術後護理措施，下列敘述何者正確？",62,{"webId":38,"stem":39,"number":40,"year":9,"session":41},"nurse-111-2-maternal-pediatric-078","小強，7 歲，罹患癲癇，有長期服用抗癲癇藥，包括 Phenytoin(Dilantin)及 Valproic acid(Depakine)，有關藥物護理指導，下列敘述何者錯誤？",78,2,{"webId":43,"stem":44,"number":45,"year":46,"session":41},"nurse-112-2-maternal-pediatric-012","張女士，G 1 P 0 ，由先生陪同待產，出現哭叫打罵情形，先生已陪產一天，出現疲憊不堪情形，詢問護理師他該怎麼辦，下列回應何者最不恰當？",12,112,{"webId":48,"stem":49,"number":50,"year":51,"session":41},"nurse-113-2-maternal-pediatric-030","張小妹，1 歲，因發燒入院，護理師欲進行生命徵象測量，有關生命徵象測量相關護理，下列何者最適切？",30,113,{"webId":53,"stem":54,"number":55,"year":56,"session":57},"nurse-114-3-maternal-pediatric-034","有關早產兒呼吸暫停的照護處置，下列敘述何者錯誤？",34,114,3,{"webId":59,"stem":60,"number":40,"year":61,"session":10},"nurse-106-1-maternal-pediatric-078","小敏，出生 6 天，罹患脊髓脊髓膜膨出，有關其手術後的護理措施，下列敘述何者錯誤？",106,"2026-09-04",1788510735910]