[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-113-2-fundamental-nursing-017":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":35,"lastmod":65},"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":27},"nurse-113-2-基本護理學與護理行政-017","nurse-113-2-fundamental-nursing-017",113,2,17,"王先生因服用毛地黃而出現脈搏短絀情況，下列敘述何者錯誤？",{"A":15,"B":16,"C":17,"D":18},"護理師需同時測量心尖脈及橈動脈來確認","因為心臟傳導功能失效而導致的脈動改變","顧慮個案隱私與舒適，所以測量 30 秒即可","測量結果心尖脈次數大於橈動脈次數","C",null,[],"本題考點在於脈搏短絀（pulse deficit）的測量與意義,屬反向題（問「何者錯誤」）。A「須同時測心尖脈與橈動脈」正確,脈搏短絀即兩者次數差;B「因心臟傳導功能失效導致的脈動改變」正確,常見於心房顫動;D「心尖脈次數大於橈動脈次數」正確,部分心搏無法傳至周邊。錯誤敘述為 C,測量脈搏短絀須由兩人同時計數完整 1 分鐘,不可只測 30 秒,以免因心律不規則而誤差,故選 C。","脈搏短絀＝心尖脈－橈動脈,反映部分心室收縮太弱無法將血打到周邊,常見於心房顫動、毛地黃中毒。測量規範:兩名護理人員同步,一測心尖(左鎖骨中線第五肋間)、一測橈動脈,同一起訖時間計滿 1 分鐘。心律不規則者一律測滿 1 分鐘不可只測 30 秒後乘 2。毛地黃中毒常伴心律不整,故需嚴密監測心尖脈,心跳過慢時須依醫囑暫停給藥。",[25,28,30,33],{"term":26,"count":27},"脈搏短絀",6,{"term":29,"count":11},"心房顫動",{"term":31,"count":32},"心尖脈與橈動脈",1,{"term":34,"count":32},"測量滿1分鐘",[36,40,45,50,55,60],{"webId":37,"stem":38,"number":39,"year":10,"session":11},"nurse-113-2-fundamental-nursing-018","有關預防一般藥物周邊靜脈注射時，發生浸潤現象，下列敘述何者錯誤？",18,{"webId":41,"stem":42,"number":43,"year":44,"session":32},"nurse-114-1-fundamental-nursing-014","下列靜脈輸液何者不是低張溶液？",14,114,{"webId":46,"stem":47,"number":48,"year":44,"session":49},"nurse-114-3-fundamental-nursing-008","病人有疼痛、呼吸困難、睡眠型態紊亂及身體心像紊亂等健康問題，應最優先處置的健康問題為何？",8,3,{"webId":51,"stem":52,"number":53,"year":54,"session":32},"nurse-106-1-fundamental-nursing-056","末期病人於意識清楚時，曾口頭表示臨終時不希望接受心肺復甦術，但尚未簽署任何意願書時，便發生意識不清，當病人出現呼吸停止時，病人的母親因為不捨，要求醫師插上氣管內插管及呼吸器，此時病人 20 歲的女兒到院時，希望能依照父親的心願撤除氣管內插管、呼吸器等維生處置，依據臺灣現行的安寧緩和醫療條例規範，下列處置何者正確？",56,106,{"webId":56,"stem":57,"number":58,"year":59,"session":11},"nurse-107-2-fundamental-nursing-020","對於心肌梗塞病人於胸痛時給與 nitroglycerin（NTG）藥物前後評估之重點，下列何者正確？①瞳孔大小 ②血壓 ③疼痛部位及程度 ④體溫",20,107,{"webId":61,"stem":62,"number":63,"year":64,"session":11},"nurse-108-2-fundamental-nursing-054","下列何者最有助於支持剛面臨親人離世家屬的哀傷情緒？",54,108,"2026-09-04",1788510754510]