[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-112-2-medical-surgical-051":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":63},"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-112-2-內外科護理學-051","nurse-112-2-medical-surgical-051",112,2,51,"評估一位氣胸且剛接上胸管病人的胸腔水下引流系統裝置，下列何者為不正常現象？",{"A":14,"B":15,"C":16,"D":17},"水封瓶內長玻管保持在液面下 2～3 公分","水封瓶內會出現連續性氣泡","水封瓶中液面在吸氣時上升","水封瓶中液面在呼氣時下降","B",null,[],"本題考點為胸腔水下引流（chest tube）系統的正常與異常判讀，屬找出不正常現象的反向題。不正常者為 B：水封瓶內出現『連續性』氣泡代表系統或胸腔有持續漏氣（air leak），屬異常，故選 B。A 正常，長玻管維持在液面下 2～3 公分以形成水封防止空氣逆流；C、D 正常，水封瓶液面隨呼吸擺動（tidaling，吸氣上升、呼氣下降）反映胸膜腔壓力變化，表示管路通暢。氣胸初期排氣時可見『間歇性』氣泡屬正常，但『連續性』氣泡須警覺漏氣。","胸腔水下引流的三個判讀重點：一是水封擺動（tidaling），隨呼吸起伏代表管路通暢，若消失可能是管路阻塞或肺已擴張；二是氣泡，氣胸排氣期間歇冒泡正常，持續冒泡代表漏氣（應由病人端往機器端逐段檢查接頭與傷口）；三是引流量與性狀。吸氣時胸腔負壓增大，水封瓶液面在患者端上升。記憶『擺動看通暢、連續氣泡是漏氣』。此為外科與重症護理極高頻的操作判讀題。",[24,27,30,32],{"term":25,"count":26},"胸腔水下引流",3,{"term":28,"count":29},"水封瓶連續性氣泡漏氣",1,{"term":31,"count":29},"潮汐擺動tidaling",{"term":33,"count":29},"氣胸引流判讀",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-112-2-medical-surgical-052","下列何者不是肺水腫病人之典型臨床表徵？",52,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-113-1-medical-surgical-018","下列何者為冠狀動脈性心臟病人服用Aspirin之主要目的？",18,113,{"webId":45,"stem":46,"number":47,"year":43,"session":26},"nurse-113-3-medical-surgical-012","承上題，有關此類病人的護理措施，下列何者最適宜？",12,{"webId":49,"stem":50,"number":51,"year":52,"session":29},"nurse-115-1-medical-surgical-010","因闌尾炎破裂而懷疑有腹膜炎病人之臨床表徵，下列何者正確？①觸診腹部僵硬           ②強烈的反彈痛 ③腸蠕動音增加    ④腹部叩診為實音",10,115,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-106-2-medical-surgical-034","有關乳癌病人荷爾蒙治療之敘述，下列何者錯誤？",34,106,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-107-2-medical-surgical-068","有關慢性腎衰竭典型之合併症，不包括下列何項？",68,107,"2026-09-04",1788510747722]