[{"data":1,"prerenderedAt":48},["ShallowReactive",2],{"q-nurse-108-1-fundamental-nursing-013":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":23},"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,"freq":11},"nurse-108-1-基本護理學與護理行政-013","nurse-108-1-fundamental-nursing-013",108,1,13,"朱太太 32 歲，因盲腸破裂引發腹膜炎而入院開刀，目前是手術後第二天，TPR：37.5℃、80 次\u002F分、 28 次\u002F分；BP：146\u002F90 mmHg；皺著眉頭一臉痛苦的告訴護理人員：「腹部傷口很痛，整晚都不敢翻身，也睡不著，現在全身都不舒服……」。張護理師針對上述情形為朱太太下了「手術後傷口疼痛」的健康問題，並以 SOAP 方式記錄，則下列何種記錄錯誤？",{"A":15,"B":16,"C":17,"D":18},"「S」：主訴腹部傷口很痛，整晚都不敢翻身","「O」：手術後第二天，皺著眉頭一臉痛苦的陳述，TPR：37.5℃、80 次\u002F分、28 次\u002F分；BP：146\u002F90 mmHg","「A」：傷口感染引發傷口疼痛","「P」：以無菌技術換藥；教導翻身時可以輕壓傷口慢慢翻身；教導減輕疼痛的方法","C",null,[],"本題考點為SOAP護理記錄中各欄位的正確歸類，特別是A（評估／護理診斷）的內容。依SOAP格式，A欄應寫下依S與O資料所形成的護理診斷或問題判斷；本題護理診斷是「手術後傷口疼痛」，但選項C的A欄卻寫「傷口感染引發傷口疼痛」，既與所立診斷不符，情境中也無感染的客觀證據（體溫僅37.5度、無膿或紅腫描述），屬錯誤推論，故C為錯誤記錄，選C。A欄的S記錄病人主訴傷口很痛正確；B的O記錄客觀觀察與生命徵象正確；D的P記錄換藥與減痛衛教等計畫正確。故答案為C。",[24,28,32,36,40,44],{"webId":25,"stem":26,"number":11,"year":27,"session":11},"nurse-106-1-fundamental-nursing-001","下列何者為預防院內感染最經濟有效的方法？",106,{"webId":29,"stem":30,"number":31,"year":27,"session":11},"nurse-106-1-fundamental-nursing-002","下列那一種健康問題會導致體溫過高？",2,{"webId":33,"stem":34,"number":35,"year":27,"session":11},"nurse-106-1-fundamental-nursing-003","王先生因腦血管損傷住院中，下列何種灌注溶液不適合王先生使用？",3,{"webId":37,"stem":38,"number":39,"year":27,"session":11},"nurse-106-1-fundamental-nursing-004","醫囑為 Acetaminophen 1 tab q6h p.r.n. if BT≧39℃之含義，下列敘述何者正確？",4,{"webId":41,"stem":42,"number":43,"year":27,"session":11},"nurse-106-1-fundamental-nursing-005","測量 H5N1 流感病毒感染病人生命徵象時，下列何項防護設備較不必要？",5,{"webId":45,"stem":46,"number":47,"year":27,"session":11},"nurse-106-1-fundamental-nursing-006","林小姐因中風導致右側肢體偏癱，住院期間有關病人之安全，下列敘述何者錯誤？",6,1783840743746]