[{"data":1,"prerenderedAt":48},["ShallowReactive",2],{"q-nurse-108-2-fundamental-nursing-055":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":24},"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":23},"nurse-108-2-基本護理學與護理行政-055","nurse-108-2-fundamental-nursing-055",108,2,55,"10\u002F09 羅先生由高處跌落，多處肋骨斷裂，有急性疼痛的問題，主責護理師於 9：30 AM 給予止痛劑，下列何者為最適當護理評值之紀錄？",{"A":15,"B":16,"C":17,"D":18},"10\u002F09 10 AM 病人主訴疼痛指數為 7 分","10\u002F09 10 AM 病人主訴疼痛改善，疼痛指數已由 7 分降至 4 分","10\u002F09 10 AM 病人能說出緩解疼痛的方法二項，如深呼吸、放鬆肌肉","10\u002F09 10 AM 病人能用助行器下床活動，且無呼吸喘的徵象","B",null,[],"本題考點為護理評值（evaluation）紀錄應對照護理目標、呈現病人反應與成效。針對「急性疼痛」問題、於9:30給藥後的評值，應記錄疼痛此一問題在措施後的改變情形。B「疼痛指數已由7分降至4分」直接以量化指標呈現止痛措施後疼痛減輕的成效，正是對應疼痛目標的評值紀錄，故為答案。A僅記錄疼痛7分屬給藥前或當下的評估數據，未顯示介入後成效，非評值。C說出緩解方法屬衛教／知識目標的評值，與本次止痛劑成效無直接對應。D能用助行器下床且無喘，對應的是活動或呼吸目標，與急性疼痛問題不相符。",1,[25,29,32,36,40,44],{"webId":26,"stem":27,"number":23,"year":28,"session":23},"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":30,"stem":31,"number":11,"year":28,"session":23},"nurse-106-1-fundamental-nursing-002","下列那一種健康問題會導致體溫過高？",{"webId":33,"stem":34,"number":35,"year":28,"session":23},"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":28,"session":23},"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":28,"session":23},"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":28,"session":23},"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？",6,1783840758369]