[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-111-2-medical-surgical-045":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"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-111-2-內外科護理學-045","nurse-111-2-medical-surgical-045",111,2,45,"皮膚表皮破皮並看得到皮下脂肪組織，且傷口出現黏液或滲出物，可能為第幾期壓傷？",{"A":14,"B":15,"C":16,"D":17},"第一期","第二期","第三期","無法分期","C",null,[],"本題考點為壓傷(壓瘡)的分期。依 NPUAP 分期標準,傷口深達皮下脂肪組織可見、可能有滲液,但未穿透至筋膜、肌肉或骨骼,屬第三期壓傷,選 C。第一期為皮膚完整、局部發紅不退白;第二期為表皮或部分真皮缺損、呈淺層潰瘍或水泡,尚未見脂肪;第四期則深及肌肉、肌腱或骨骼。若傷口被壞死組織(腐肉或焦痂)覆蓋無法判斷深度才是「無法分期」。本題「看得到皮下脂肪」正是第三期的分界特徵。","壓傷分期以「組織缺損深度」為軸記憶:一期—皮膚完整、發紅不退白(僅表皮下受損);二期—部分皮層缺損、淺潰瘍或漿液性水泡(達真皮);三期—全層皮膚缺損、可見皮下脂肪,但未及筋膜(關鍵標誌就是「看得到脂肪」);四期—全層加深部組織缺損,可見肌肉、肌腱或骨骼。另有「無法分期」(全層缺損但被腐肉\u002F焦痂遮蓋)與「深部組織壓傷」(完整或水泡皮膚下呈紫褐色)。此題以「皮下脂肪+滲出物」直指第三期,是最典型的分期判別點。",[24,27,29,31],{"term":25,"count":26},"壓傷分期",1,{"term":28,"count":26},"NPUAP 分期標準",{"term":30,"count":26},"第三期全層皮膚缺損",{"term":32,"count":26},"皮下脂肪可見",[34,38,43,47,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-111-2-medical-surgical-046","有關皮膚惡性腫瘤病人的護理措施，下列何者錯誤？",46,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-112-1-medical-surgical-062","有關逆行性腎盂造影術之敘述，下列何者正確？①檢查前評估病人有無鋇劑過敏病史 ②檢查前衛教病人勿排空膀胱 ③此檢查使用的顯影劑不會進入血流 ④檢查後監測病人有無尿瀦留、感染、血尿情形",62,112,{"webId":44,"stem":45,"number":46,"year":42,"session":10},"nurse-112-2-medical-surgical-076","選擇鼻咽人工氣道適當尺寸之量測方式，下列何者正確？",76,{"webId":48,"stem":49,"number":50,"year":51,"session":52},"nurse-113-3-medical-surgical-044","有關糖尿病病人足部護理的指導，下列何者正確？①每日以溫水清洗足部前須以手背測試水溫，以防燙傷 ②修剪趾甲應剪短於足趾末端，以防甲溝炎 ③平日於足部與足趾間及腳跟龜裂處，塗抹保養乳液，以免皮膚過於乾燥 ④不可擅自用手或剪刀，將足部硬繭或雞眼剝除",44,113,3,{"webId":54,"stem":55,"number":56,"year":57,"session":26},"nurse-115-1-medical-surgical-048","有關有機磷中毒臨床處置之敘述，下列何者錯誤？",48,115,{"webId":59,"stem":60,"number":41,"year":61,"session":10},"nurse-106-2-medical-surgical-062","正常成年人，若膀胱容積壓力正常，最大尿流速低於下列何者即顯示尿道出口有阻塞現象？",106,"2026-09-04",1788510738632]