[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-113-3-fundamental-nursing-026":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"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-113-3-基本護理學與護理行政-026","nurse-113-3-fundamental-nursing-026",113,3,26,"根據下列四位住院病人生命徵象測量的結果，何者最為緊急需優先處理？",{"A":15,"B":16,"C":17,"D":18},"22 歲男性，急性闌尾炎，預計接受闌尾切除術，體溫 37.8℃，脈搏 80 次／分，呼吸 20 次／分，血壓 140\u002F80 mmHg","40 歲女性，流行性感冒合併肺炎，主訴呼吸喘，體溫 38.5℃，脈搏 90 次／分，呼吸 30 次／分，血壓 120\u002F76 mmHg","55 歲女性，昨天右側乳房切除，主訴傷口疼痛，體溫 37.5℃，脈搏 82 次／分，呼吸 22 次／分，血壓 146\u002F86 mmHg","88 歲男性，蜂窩性組織炎，目前抗生素使用，體溫 38.2℃，脈搏 96 次／分，呼吸 20 次／分，血壓 130\u002F96 mmHg","B",null,[],"本題考點在於依生命徵象判斷病情緊急程度、決定處理優先順序。依 ABC（呼吸道、呼吸、循環）與生命徵象異常幅度評估，選項 B 女性肺炎合併主訴呼吸喘、呼吸速率 30 次\u002F分（成人正常 12～20），已屬明顯呼吸窘迫，可能進展為呼吸衰竭與缺氧，威脅氣道與呼吸最為立即，故優先，選 B。A 闌尾炎生命徵象大致穩定，屬計畫性手術。C 乳房術後疼痛、血壓略高但無立即危險。D 蜂窩性組織炎已在使用抗生素、生命徵象輕度異常但穩定。依「呼吸問題優先於其他」原則，B 需最先處理。","急重症分級依 ABC 順序，呼吸速率是最敏感的惡化早期指標之一，>30 或 \u003C8 均屬警訊（early warning score 高分項）。缺氧造成的損害進展快且不可逆，故凌駕於發燒、疼痛、血壓輕度升高等問題。記「數字最偏離正常且威脅 ABC 者先處理，呼吸喘＋RR 30 就是紅旗」。",[25,28,30,32],{"term":26,"count":27},"呼吸速率正常值",1,{"term":29,"count":27},"ABC 評估優先",{"term":31,"count":27},"呼吸窘迫辨識",{"term":33,"count":27},"生命徵象分級",[35,39,45,50,55,60],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-113-3-fundamental-nursing-027","病人因子宮頸癌進行子宮切除手術，術後使用束腹帶，下列何者不是此時使用束腹帶之目的？",27,{"webId":40,"stem":41,"number":42,"year":43,"session":44},"nurse-114-2-fundamental-nursing-023","成人病人近期發燒，一天內有時體溫達 39℃以上，有時又會突然降到正常值以下，如此交替出現的發燒型態，最可能出現在下列何種疾病？",23,114,2,{"webId":46,"stem":47,"number":48,"year":49,"session":27},"nurse-115-1-fundamental-nursing-017","有關輸血注意事項，下列敘述何者正確？①每單位血品最好在2小時內輸完              ②可應用輸血加壓器來協助輸血（壓力＞300 mmHg）    ③使用輸血加溫器，溫度以38℃～40℃為原則        ④最初15分，滴速宜維持20～40 gtt\u002Fmin",17,115,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-106-2-fundamental-nursing-035","為中風老人翻身側臥擺位時，下列敘述何者不適當？",35,106,{"webId":56,"stem":57,"number":58,"year":59,"session":44},"nurse-107-2-fundamental-nursing-079","護理長計算單位每天每位病人所得護理時數時，下列何種資料未涵括其中？",79,107,{"webId":61,"stem":62,"number":63,"year":64,"session":27},"nurse-109-1-fundamental-nursing-033","協助王老先生執行床上擦澡，下列敘述何者正確？",33,109,"2026-09-04",1788510752142]