[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-111-2-medical-surgical-054":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":61},"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-054","nurse-111-2-medical-surgical-054",111,2,54,"有關移除胸管的護理措施，下列何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"水封瓶液面，隨呼吸上下浮動，表示可拔除胸管","拔管前，應提前給予止痛劑","拔管時，應請病人深吸氣後閉氣再拔出胸管","拔管後，應以無菌凡士林紗布覆蓋傷口","A",null,[],"本題考點在於胸管移除的正確指標與步驟，選錯誤者。水封瓶液面隨呼吸上下浮動（tidaling）代表胸腔與引流系統相通、肺尚未完全擴張，是引流仍在運作的正常現象，並非可拔管依據；真正可拔管的指標是引流量顯著減少、無漏氣、X光顯示肺已復張，故 A 敘述錯誤為答案。考點在於區分「系統運作正常」與「可拔除」是兩回事。B 拔管會牽扯胸壁與肋膜引起疼痛，事前給止痛劑正確。C 拔管時請病人深吸氣後閉氣（做 Valsalva 動作），使胸腔內壓上升、防止空氣趁隙進入肋膜腔造成氣胸，做法正確。D 拔管後以無菌凡士林紗布密封傷口可防止空氣經傷口進入，做法正確。","水封瓶三大觀察：tidaling（隨呼吸浮動，正常）、bubbling（持續冒泡代表漏氣，需查管路）、引流量。tidaling 消失可能是肺已復張，也可能是管路阻塞或扭折，須並看引流量與X光判讀。拔管口訣：先止痛、閉氣拔、凡士林封，避免開放性氣胸。",[24,27,29,32],{"term":25,"count":26},"Valsalva 動作",3,{"term":28,"count":10},"胸管引流",{"term":30,"count":31},"水封瓶 tidaling",1,{"term":33,"count":31},"氣胸預防",[35,39,44,48,52,57],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-111-2-medical-surgical-055","有關慢性支氣管炎病人出院護理指導的敘述，下列何者正確？",55,{"webId":40,"stem":41,"number":42,"year":43,"session":31},"nurse-112-1-medical-surgical-071","承上題，陳小姐近期藥物治療反應不佳而入院接受甲狀腺切除術，有關甲狀腺切除手術，下列何者正確？①為維持正常的甲狀腺功能，一般採用次全甲狀腺切除 ②出血、聲門水腫、急性呼吸道阻塞為常見的術後合併症 ③術後聲音沙啞是因雙側喉返神經受傷所致 ④術後需評估病人有無肌肉抽搐之甲狀腺功能低下表徵",71,112,{"webId":45,"stem":46,"number":47,"year":43,"session":26},"nurse-112-3-medical-surgical-005","有關巴金森氏症病人的自我照顧指導，下列敘述何者錯誤？",5,{"webId":49,"stem":50,"number":26,"year":51,"session":31},"nurse-114-1-medical-surgical-003","有關頭部外傷相關合併症的敘述，下列何者正確？",114,{"webId":53,"stem":54,"number":55,"year":56,"session":10},"nurse-115-2-medical-surgical-007","有關急性膽囊炎的敘述，下列何者正確？",7,115,{"webId":58,"stem":59,"number":42,"year":60,"session":10},"nurse-106-2-medical-surgical-071","有關尿崩症病人的出院護理指導，下列何者不適當？",106,"2026-09-04",1788510738714]