[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-115-2-fundamental-nursing-023":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":27},"nurse-115-2-基本護理學與護理行政-023","nurse-115-2-fundamental-nursing-023",115,2,23,"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？",{"A":15,"B":16,"C":17,"D":18},"測量前應先評估病人 30 分鐘前有無運動、吸菸影響體溫測量的行為","腋溫測量法是此病人最適當測量的方式","若耳溫測量結果為 35.8℃，應準備病人急救","若懷疑體溫測量結果，同時間重複測量應採用最高的溫度數據","D",null,[],"本題考點是體溫測量的部位選擇與數據判讀原則。當結果與病人臨床表現不符而懷疑其準確性時,同時重複測量後應取最高的數值,因為多數誤差來源如測量時間不足、儀器未貼合、探頭方向偏移與環境散熱,都會使讀值偏低而非偏高,故 D 正確。A 錯在評估運動、吸菸與進食飲水影響屬口溫的準備事項,對意識昏迷者本就不採口溫。B 錯在長期臥床且多消瘦的昏迷者腋窩不易夾緊、所需時間長,並非最適當部位。C 錯在耳溫 35.8 度僅略低於正常範圍,未達體溫過低的判定,不足以構成啟動急救的依據。","各部位參考值大致為肛溫 36.6 至 38 度、口溫 36.4 至 37.5 度、腋溫 35.9 至 37 度,耳溫最接近核心溫度;高低順序是肛溫最高、腋溫最低,相鄰約差 0.5 度。體溫過低的分級起點約在核心溫度低於 35 度。誤差方向記成「接觸不足者偏低」,因此重複測量取高值。長期臥床昏迷者實務上多選耳溫或肛溫,而肛溫的相對禁忌包括腹瀉、肛門手術、心肌梗塞後與新生兒。",[25,28,30,32],{"term":26,"count":27},"體溫測量部位選擇",1,{"term":29,"count":27},"腋溫與耳溫",{"term":31,"count":27},"測量誤差判讀",{"term":33,"count":27},"體溫過低判定",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-115-2-fundamental-nursing-024","有關測量頸動脈搏動的敘述，下列何者正確？",24,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-106-1-fundamental-nursing-070","以危機管理策略而言，醫學中心應採取下列何項較為適宜？",70,106,{"webId":45,"stem":46,"number":47,"year":48,"session":27},"nurse-107-1-fundamental-nursing-004","適用外科無菌之護理技術，包括下列那幾項？①灌腸 ②點滴加藥 ③肌肉注射 ④單次導尿 ⑤傷口換藥",4,107,{"webId":50,"stem":51,"number":52,"year":53,"session":27},"nurse-108-1-fundamental-nursing-042","病人因車禍導致身體多處挫傷，車禍當時呼吸急促、感覺呼吸不順、血壓下降，下列何者是造成病人呼吸變化最有可能的原因？",42,108,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-109-2-fundamental-nursing-006","病歷的生命徵象紀錄表中不會出現下列何種資料？",6,109,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-110-2-fundamental-nursing-040","黃先生為糖尿病病人，血糖控制不佳住院，右足背有一傷口，外觀紅腫，有關足部護理措施，下列何者最適當？",40,110,"2026-08-06",1787299031681]