[{"data":1,"prerenderedAt":65},["ShallowReactive",2],{"q-nurse-115-2-fundamental-nursing-026":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-026","nurse-115-2-fundamental-nursing-026",115,2,26,"病人骨折住院，無慢性病，今早護理人員測得耳溫 38.5℃，脈搏 90 次／分，呼吸 26 次／分，血壓為 110／64 mmHg，血氧濃度（SpO 2 ）為 89%，其異常的數值有下列何者？①體溫 ②脈搏 ③呼吸 ④血壓 ⑤血氧濃度",{"A":15,"B":16,"C":17,"D":18},"①②④","①③⑤","②③⑤","③④⑤","B",null,[],"本題考點是成人生命徵象與血氧飽和度正常範圍的判讀。①耳溫 38.5℃ 屬異常，耳溫（鼓膜溫）一般以 38℃ 以上界定為發燒，且耳溫比口溫略高約 0.3 至 0.6℃。③呼吸 26 次／分超出成人 12 至 20 次／分的範圍，屬呼吸過速。⑤SpO₂ 89% 低於一般以 95% 以上為正常的標準，已落在低血氧範圍。②脈搏 90 次／分仍在成人 60 至 100 次／分之內，雖偏快但未超出範圍；④血壓 110／64 mmHg 的收縮壓與舒張壓皆落在成人正常區間，也未達高血壓或低血壓的判定標準，兩項都不算異常。綜合判讀，異常者為①體溫、③呼吸與⑤血氧濃度，故選 B。","血氧的數值意義要接上氧解離曲線：SpO₂ 90% 大約對應 PaO₂ 60 mmHg，這裡正是曲線由平坦段轉為陡降段的轉折點，SpO₂ 再往下掉一點點，PaO₂ 就會大幅下降，這是把 90% 當成警戒線的生理依據。體溫測量部位的高低順序可記「肛＞耳＞口＞腋」，換部位比較數值時要先換算基準，否則會把正常值判成發燒。本題情境是骨折住院且無慢性病，體溫升高伴呼吸急促與血氧下降，臨床鑑別會連結到創傷後的疼痛與代償、肺擴張不全、脂肪栓塞症候群與肺栓塞等機轉，這也是國考把「發燒＋呼吸快＋血氧低」三項湊在骨折病人身上的設計用意。",[25,28,30,32],{"term":26,"count":27},"成人生命徵象正常範圍",1,{"term":29,"count":27},"耳溫發燒界定",{"term":31,"count":27},"血氧飽和度與氧解離曲線",{"term":33,"count":27},"呼吸過速",[35,39,44,49,54,59],{"webId":36,"stem":37,"number":38,"year":10,"session":11},"nurse-115-2-fundamental-nursing-027","有關半坐臥時壓力性損傷的好發部位，下列何者錯誤？",27,{"webId":40,"stem":41,"number":42,"year":43,"session":27},"nurse-106-1-fundamental-nursing-073","每位病人在住院到出院均有一位固定之護理師負責提供照護計畫，以達整體性、連續性及個別性的目的，此為何種護理模式？",73,106,{"webId":45,"stem":46,"number":47,"year":48,"session":27},"nurse-107-1-fundamental-nursing-007","朱先生剛出獄不久，隨後因疑似肝硬化而入院接受檢查與治療，護理師正與其進行治療性溝通。治療性溝通的目的不包含下列何項？",7,107,{"webId":50,"stem":51,"number":52,"year":53,"session":27},"nurse-108-1-fundamental-nursing-045","有關促進吳太太睡眠之護理措施，下列敘述何者錯誤？",45,108,{"webId":55,"stem":56,"number":57,"year":58,"session":11},"nurse-109-2-fundamental-nursing-009","有關需要更換存留導尿管情況之敘述，下列何者正確？①尿液 pH 值呈弱酸性 ②尿道分泌物有異臭味 ③出現絮狀沉澱物，致引流不暢 ④導管更換時間依材質而定 ⑤病人有尿液滲漏情形",9,109,{"webId":60,"stem":61,"number":62,"year":63,"session":11},"nurse-110-2-fundamental-nursing-043","下列病人情境，何者適合執行灌腸？",43,110,"2026-08-06",1787299031713]