[{"data":1,"prerenderedAt":48},["ShallowReactive",2],{"q-nurse-108-1-fundamental-nursing-054":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-054","nurse-108-1-fundamental-nursing-054",108,1,54,"柯老太太，82 歲，身上多處壓瘡傷口，入院時 GCS：E4V5M5，BP：118\u002F78 mmHg，體溫 37.6℃， 24 小時後柯老太太出現下列何種情況需立即報告？",{"A":15,"B":16,"C":17,"D":18},"GCS：E3V4M4","體溫 37.8℃","血壓：98\u002F60 mmHg","白班的輸入量：1050 c.c.，輸出量：650 c.c.","A",null,[],"本題考點是依病情變化判斷何者需立即通報。原則是意識狀態惡化屬神經功能急遽變化的紅旗。入院時昏迷指數為E4V5M5(14分),24小時後A項變為E3V4M4(11分),下降3分且各項退步,顯示意識明顯惡化,可能為顱內或全身病況急轉,需立即報告,故選A。B體溫由37.6℃升為37.8℃僅微幅變化,無立即危險;C血壓由118\u002F78降為98\u002F60雖略降,收縮壓仍近100mmHg,尚在可觀察範圍;D白班輸入1050c.c.、輸出650c.c.,輸出量正常、水分平衡合理,無異常。相較之下,唯A的昏迷指數顯著下降代表病情惡化,最需優先通報。",[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？",6,1783840744086]