[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-114-2-fundamental-nursing-019":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":66},"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-114-2-基本護理學與護理行政-019","nurse-114-2-fundamental-nursing-019",114,2,19,"護理師為病人翻身擺位時，下列何者最為適當？",{"A":15,"B":16,"C":17,"D":18},"每位臥床病人至少每四小時翻身一次","仰臥時在膝膕處放置軟枕可避免病人下滑至床尾","側臥時勿在病人的頸椎、腰部墊上軟枕以維持脊椎平直","協助採側卧時須加強肩部和髖部的皮膚護理","D",null,[],"本題考點在於翻身擺位與皮膚完整性維護原則。依基本護理學，協助病人採側臥時，肩部與髖部為骨突受壓處，須加強該處皮膚護理與觀察以預防壓傷，故 D 最適當為答案。A 錯誤：臥床病人一般至少每「兩小時」翻身一次而非四小時，以免壓傷。B 錯誤：膝膕下墊枕與防止下滑無關，防下滑應於足底支撐；且膝膕久壓恐影響循環。C 錯誤：側臥時反而需在適當部位墊枕支托維持脊椎中立與舒適，而非一律不墊，故均不符。","壓傷好發於骨突處：仰臥看薦骨、腳跟、枕部；側臥看肩、髖（大轉子）、外踝、耳；坐姿看坐骨。翻身頻率以「至少每 2 小時」為基準，配合減壓工具與皮膚評估（Braden 量表）。膝膕下長時間墊枕會壓迫膕動脈與腓神經，屬禁忌。記憶：側臥顧肩髖、每 2 小時翻、骨突要減壓。",[25,28,30,32,34],{"term":26,"count":27},"翻身擺位",1,{"term":29,"count":27},"壓傷好發骨突處",{"term":31,"count":27},"每2小時翻身",{"term":33,"count":27},"側臥皮膚護理",{"term":35,"count":27},"膝膕墊枕禁忌",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-114-2-fundamental-nursing-020","病人因肺炎住院，右手打點滴抗生素滴注，護理師協助更換衣服的步驟，下列何者較為適切？",20,{"webId":42,"stem":43,"number":44,"year":45,"session":27},"nurse-115-1-fundamental-nursing-016","王太太使用坐浴後，主訴頭暈、心跳加快、無力、臉色蒼白，此時最適切的護理措施為何？",16,115,{"webId":47,"stem":48,"number":49,"year":50,"session":27},"nurse-106-1-fundamental-nursing-010","有關專業性人際關係結束期的護理重點，下列何者正確？",10,106,{"webId":52,"stem":53,"number":54,"year":55,"session":27},"nurse-107-1-fundamental-nursing-048","75 歲王先生診斷中風，左側肢體肌力 1 分，右側 5 分，身上有點滴持續灌注、鼻胃管、及氣切管並連接呼吸器使用中，王先生意識不清，會不自主的將管路拔除，下列處置何者正確？",48,107,{"webId":57,"stem":58,"number":59,"year":60,"session":11},"nurse-108-2-fundamental-nursing-012","以 C.T.M.S.原則評估病人肢體約束時，下列敘述何者正確？",12,108,{"webId":62,"stem":63,"number":64,"year":65,"session":11},"nurse-109-2-fundamental-nursing-046","有關影響營養狀況之因素，下列何者正確？",46,109,"2026-09-04",1788510759117]