[{"data":1,"prerenderedAt":48},["ShallowReactive",2],{"q-nurse-110-1-fundamental-nursing-056":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-110-1-基本護理學與護理行政-056","nurse-110-1-fundamental-nursing-056",110,1,56,"趙先生 68 歲，意識清楚，診斷肝硬化合併食道靜脈曲張，血小板：22,000\u002FμL，痰乾且量少，因病人發燒寒顫，醫師開立收集痰液培養（sputum culture）之醫囑，護理人員應如何執行最為適當？",{"A":15,"B":16,"C":17,"D":18},"以抽痰方式取得痰液，抽吸壓力維持於 150～170mmHg","鼓勵病人深呼吸後，立刻用力咳出痰液","鼓勵先以漱口劑清潔口腔，避免標本污染","先給予 0.45% NaCl 噴霧吸入，稀釋痰液後配合呼氣咳痰","D",null,[],"本題考點在合併食道靜脈曲張與血小板過低（22,000\u002FμL）病人採痰的安全考量。依出血風險評估，此病人凝血功能差、食道靜脈易破裂，應避免抽痰負壓損傷及用力咳嗽引發的腹壓上升。選項 D 以 0.45% NaCl 噴霧吸入稀釋濃稠痰液、再配合呼氣輕咳，最為溫和安全，故為正解。A 抽痰負壓 150～170 mmHg 易造成黏膜損傷出血，不宜。B「立刻用力咳出」會驟增腹內壓，恐誘發食道靜脈曲張破裂出血。C 漱口雖可減污染，但無法解決痰乾量少的取樣困難，非最適當處置。",[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？",6,1783840761792]