[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-114-3-fundamental-nursing-026":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":34,"lastmod":64},"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-114-3-基本護理學與護理行政-026","nurse-114-3-fundamental-nursing-026",114,3,26,"測量呼吸時注意事項，下列何者最不適當？",{"A":15,"B":16,"C":17,"D":18},"測量前要先告訴病人，增加其準備度","測量前評估病人是否剛進食或運動","觀察病人是否使用呼吸輔助肌","測量時應評估病人面部表情和膚色","A",null,[],"本題考點在於測量呼吸速率的正確技巧，屬反向題，須找出最不適當者。呼吸是唯一同時受自主與隨意控制的生命徵象，測量前若事先告知病人，會使其刻意調整呼吸而失真，故臨床上通常在測完脈搏後、手仍按在病人手腕上，於其不察覺時觀察呼吸，因此錯誤（最不適當）敘述為 A。B 測量前評估病人是否剛進食或運動，因其會暫時影響呼吸速率，屬正確考量。C 觀察是否使用呼吸輔助肌可判斷呼吸費力程度，正確。D 評估面部表情與膚色（如發紺）能反映氧合狀態，正確。逐項比對後，唯 A 的『事先告知以增加準備度』違反呼吸測量不宜提醒的原則，故為答案。","呼吸受延腦呼吸中樞自主調控，但大腦皮質可短暫隨意介入，這正是『不可預告』的生理依據。標準做法是接續脈搏測量、假裝仍在數脈搏，觀察一次完整吸吐為一次呼吸，計數一分鐘（尤其嬰幼兒或不規則者）。同時評估三要素：速率、深度（潮氣量）、節律，並觀察費力徵象（鼻翼搧動、胸凹、使用輔助肌）與膚色。記憶：脈搏『先告知、可預告』，呼吸『不告知、偷偷數』，這是兩者測量流程最大差異。",[25,27,29,32],{"term":26,"count":11},"呼吸輔助肌",{"term":28,"count":11},"生命徵象評估",{"term":30,"count":31},"呼吸測量技巧",1,{"term":33,"count":31},"呼吸自主與隨意控制",[35,39,45,50,55,60],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-114-3-fundamental-nursing-027","有關壓力性損傷的預防方法，下列何者最適當？",27,{"webId":40,"stem":41,"number":42,"year":43,"session":44},"nurse-115-2-fundamental-nursing-023","護理師協助意識昏迷且已臥床三個月的 80 歲病人測量體溫時，下列關於體溫測量技術與結果判讀，何者正確？",23,115,2,{"webId":46,"stem":47,"number":48,"year":49,"session":31},"nurse-106-1-fundamental-nursing-067","某病房有 40 床，今天占床率 80%，第一、二、三、四類病人嚴重度，分別是 0.3、0.8、1.5 和 2。病房中四類病人比數分別是 3：3：1：1。該病房今天的工作量指數是：",67,106,{"webId":51,"stem":52,"number":53,"year":54,"session":44},"nurse-107-2-fundamental-nursing-025","有關全身和局部用冷熱療法的敘述，下列何者正確？①冷熱應用面積越大，效果越好，耐受力也越佳 ②全身用熱則會使血管擴張血循改變，腦血流減少導致頭暈 ③全身用熱時間如果過長，就會產生交感反應，而讓血管擴張更加厲害 ④全身用冷熱的危險性較局部使用冷熱療法為大",25,107,{"webId":56,"stem":57,"number":58,"year":59,"session":44},"nurse-108-2-fundamental-nursing-069","臺灣護理學會於 1992 年接受行政院衛生署委託辦理「醫院基層護理人員專業能力進階制度」，至今已經在各大醫院實施。小煦畢業後，一直積極參與進階制度培育專業能力，最近她報名參加訓練課程的主題包括：重症病人護理、困難病人護理、醫療糾紛案例討論，小煦正在準備那一個層級的進階？",69,108,{"webId":61,"stem":62,"number":42,"year":63,"session":31},"nurse-110-1-fundamental-nursing-023","局部用冷會產生那些生理現象？①減輕組織腫脹 ②鬆弛僵硬的組織 ③降低細胞新陳代謝 ④容易導致寒顫發生 ⑤減輕疼痛",110,"2026-09-04",1788510761635]