[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-112-2-medical-surgical-029":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":10},"nurse-112-2-內外科護理學-029","nurse-112-2-medical-surgical-029",112,2,29,"有關心臟節律器放置術後護理措施之敘述，下列何者不適宜？",{"A":14,"B":15,"C":16,"D":17},"心電圖上出現心室激搏波（spike）時，應立即通知醫師","每日評估植入處傷口有無發炎、血腫情形","術後隔日，植入側的手臂宜避免抬高的關節運動","術後第一小時應每 15 分鐘評估生命徵象","A",null,[],"本題考點是心臟節律器（pacemaker）置放術後的護理措施，不適宜的是 A。依節律器的運作原理，節律器藉電脈衝刺激心臟收縮，心電圖上出現的「激搏波（spike）」正是節律器正常放電的訊號，代表裝置運作中，屬預期且正常的表現，並不需要立即通知醫師，故 A 不適宜而為答案（真正需通報的是 spike 後未跟隨心跳的「失奪獲 failure to capture」等異常）。B 每日評估植入處傷口有無發炎、血腫，正確；C 術後早期植入側手臂避免抬高過肩的關節活動，以防電極線脫位，正確；D 術後第一小時每 15 分鐘監測生命徵象以早期發現併發症，正確。","節律器術後護理重點在「防止電極脫位、觀察併發症、辨識裝置功能」。心電圖上的 spike 是節律器放電的正常標記，需觀察的異常是：spike 後沒有心室或心房去極化波（failure to capture）、該放電時不放電（failure to sense\u002Foutput）、或亂放電，這些才需通報。其他重要衛教與監測：植入側手臂初期避免過度上舉與提重物（約數週）以免電極移位、觀察傷口感染與血腫、注意呃逆或胸壁跳動（可能導線移位刺激橫膈）、避免強電磁場、隨身攜帶識別卡並定期回診檢測電池與閾值。本題設計的核心陷阱是把「正常運作訊號」誤當「異常警訊」，理解 spike 的意義即可正確辨識。",[24,26,29,31],{"term":25,"count":10},"心臟節律器",{"term":27,"count":28},"心電圖激搏波(spike)",1,{"term":30,"count":28},"電極脫位預防",{"term":32,"count":28},"術後併發症觀察",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-112-2-medical-surgical-030","有關血管產生動脈粥狀硬化（atherosclerosis）的病理機轉，下列敘述何者錯誤？",30,{"webId":39,"stem":40,"number":41,"year":9,"session":42},"nurse-112-3-medical-surgical-046","有關糖尿病病人飲食控制原則的護理指導，下列何者正確？",46,3,{"webId":44,"stem":45,"number":46,"year":47,"session":10},"nurse-113-2-medical-surgical-040","王先生，85 歲，因排尿燒灼感、疼痛且出現膿尿、血尿至急診求治，生命徵象正常，有關其進一步之評估與檢查，下列何者錯誤？",40,113,{"webId":49,"stem":50,"number":51,"year":52,"session":42},"nurse-114-3-medical-surgical-038","有關活體腎臟移植捐贈者，下列敘述何者最不適當？",38,114,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-106-2-medical-surgical-012","有關食道癌的敘述，下列何者錯誤？",12,106,{"webId":59,"stem":60,"number":41,"year":61,"session":10},"nurse-107-2-medical-surgical-046","有關疥瘡的敘述，下列何者錯誤？",107,"2026-09-04",1788510747523]