[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-113-1-fundamental-nursing-027":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":31,"lastmod":62},"基本護理學與護理行政","fundamental-nursing","基本護理學(包括護理原理、護理技術)與護理行政",{"id":8,"webId":9,"year":10,"session":11,"subject":4,"number":12,"stem":13,"options":14,"answer":19,"answerNote":20,"images":21,"explanation":22,"explanationDeep":23,"topics":24,"freq":11},"nurse-113-1-基本護理學與護理行政-027","nurse-113-1-fundamental-nursing-027",113,1,27,"下列何種徵象顯示成人鼻胃管插入的位置錯誤？",{"A":15,"B":16,"C":17,"D":18},"鼻胃管固定的標記顯示為70公分","鼻胃管反抽，抽出100 c.c.未消化的食物","灌食空針打入30 c.c.空氣，胃部聽診時有空氣進入胃的咕嚕聲音","將鼻胃管末端放入水中，無連續性氣泡","A",null,[],"本題考點在於成人鼻胃管位置正確性的判定，為反向題，問顯示位置「錯誤」者。錯誤徵象為 A：成人鼻胃管插入長度（鼻尖—耳垂—劍突）約 45～55 公分，固定標記顯示 70 公分表示插入過深、位置錯誤（可能過胃入十二指腸或盤繞），故選 A。B 反抽出未消化食物、C 打氣聽診胃部有咕嚕氣過水聲、D 末端置水中無連續氣泡（表示未誤入氣管），皆為位置正確的佐證。判斷關鍵在於插入深度的正常範圍。","鼻胃管定位確認法：測量 NEX（鼻—耳—劍突）約 45–55 公分；反抽胃內容物觀察量與酸鹼（pH≤5.5 支持在胃）、打氣聽診、置水無氣泡排除誤入呼吸道；最可靠仍為 X 光。深度異常（如 70 公分）是最直接的錯位訊號。灌食前多重確認可避免吸入性肺炎，是此題的安全核心。",[25,27,29],{"term":26,"count":11},"鼻胃管定位",{"term":28,"count":11},"插入長度 45-55 公分",{"term":30,"count":11},"位置確認方法",[32,36,41,47,52,57],{"webId":33,"stem":34,"number":35,"year":10,"session":11},"nurse-113-1-fundamental-nursing-028","有關營養素的敘述，下列何者正確？",28,{"webId":37,"stem":38,"number":39,"year":10,"session":40},"nurse-113-3-fundamental-nursing-024","有關影響血壓因素之敘述，下列何者正確？",24,3,{"webId":42,"stem":43,"number":44,"year":45,"session":46},"nurse-114-2-fundamental-nursing-018","有關神經病變性麻刺痛之疼痛輔佐劑（adjuvant drugs）的選擇，根據疼痛評估原則，PQRST 那一項目最適當？",18,114,2,{"webId":48,"stem":49,"number":50,"year":51,"session":11},"nurse-106-1-fundamental-nursing-016","承上題，若要教導李老先生如何注射胰島素，下列何者正確？",16,106,{"webId":53,"stem":54,"number":55,"year":56,"session":11},"nurse-107-1-fundamental-nursing-060","主任上述之建議是屬於下列何種建立護理專業形象之作為？",60,107,{"webId":58,"stem":59,"number":60,"year":61,"session":46},"nurse-108-2-fundamental-nursing-014","有關臺灣 2012 年修訂的「腦死判定準則」，下列敘述何者錯誤？",14,108,"2026-09-04",1788510750032]