[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-112-3-medical-surgical-035":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":35,"lastmod":66},"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-112-3-內外科護理學-035","nurse-112-3-medical-surgical-035",112,3,35,"病人的動脈血液氣體分析報告為 pH 7.36，PaO 2 88 mmHg，PaCO 2 50 mmHg，HCO 3- 25 mEq\u002FL，下列措施何者應為最優先？",{"A":14,"B":15,"C":16,"D":17},"立即通知主治醫師","為病人戴上氧氣鼻套管","用脈衝式血氧測定儀測量","協助病人翻身並鼓勵其深呼吸咳嗽","D",null,[],"本題考點在於動脈血液氣體分析判讀與優先處置。pH 7.36仍在正常範圍下緣、PaCO₂ 50 mmHg略偏高、HCO₃⁻ 25 mEq\u002FL正常、PaO₂ 88 mmHg尚可,顯示輕微二氧化碳滯留但代償尚可、無立即危及生命。此情境優先協助病人翻身並鼓勵深呼吸咳嗽,以促進換氣、排出二氧化碳並預防肺塌陷,故選D。A立即通知醫師、B戴氧氣鼻套管、C重測血氧,在生命徵象穩定下均非最優先。","ABG判讀步驟:先看pH偏酸或偏鹼,再看PaCO₂(呼吸性)與HCO₃⁻(代謝性)何者為主因,最後判斷代償程度。本題pH正常偏低、CO₂略升而HCO₃⁻正常,屬輕度呼吸性酸中毒,護理處置以改善通氣為先,而非侵入或警急動作。PaO₂正常值約80–100 mmHg。",[24,27,30,33],{"term":25,"count":26},"動脈血液氣體分析",10,{"term":28,"count":29},"呼吸性酸中毒",8,{"term":31,"count":32},"PaCO2\u002FHCO3−判讀",1,{"term":34,"count":32},"護理優先次序",[36,40,46,51,56,61],{"webId":37,"stem":38,"number":39,"year":9,"session":10},"nurse-112-3-medical-surgical-036","有關執行氣切造口術病人抽痰的敘述，下列何者不適當？",36,{"webId":41,"stem":42,"number":43,"year":44,"session":45},"nurse-113-2-medical-surgical-032","有關鞏皮症（進行性系統性硬化症，progressive system sclerosis）護理指導之敘述，下列何者錯誤？",32,113,2,{"webId":47,"stem":48,"number":49,"year":50,"session":32},"nurse-114-1-medical-surgical-026","有關致癌因子及其相關癌症的敘述，下列何者需進一步提供護理指導以澄清誤解？",26,114,{"webId":52,"stem":53,"number":54,"year":55,"session":45},"nurse-115-2-medical-surgical-024","一位癌症病人檢查及評估結果如下：血壓 105\u002F65 mmHg，呼吸 20 次／分，心電圖顯示正常竇性心律，鉀離子 4.1 mmol\u002FL，尿酸 5.5 mg\u002FdL，血鈣 9.2 mg\u002FdL，蹠反射強直，無水腫症狀。病人最可能罹患下列何種腫瘤急症？",24,115,{"webId":57,"stem":58,"number":59,"year":60,"session":32},"nurse-107-1-medical-surgical-018","有關下肢截肢手術後的護理措施，下列何者錯誤？",18,107,{"webId":62,"stem":63,"number":64,"year":65,"session":32},"nurse-108-1-medical-surgical-052","肺結核病人若無法遵從醫師所開立的醫囑規則服藥時之護理措施，下列何者最適當？",52,108,"2026-09-04",1788510745086]