[{"data":1,"prerenderedAt":67},["ShallowReactive",2],{"q-nurse-115-2-fundamental-nursing-033":3},{"subject":4,"subjectSlug":5,"subjectFullName":6,"question":7,"related":36,"lastmod":66},"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":11},"nurse-115-2-基本護理學與護理行政-033","nurse-115-2-fundamental-nursing-033",115,2,33,"病人因肺部電腦斷層出現陰影而初次入院，有關入院護理之敘述，下列何者最適當？",{"A":15,"B":16,"C":17,"D":18},"進行身體評估及詢問病史","介紹可能發生相同疾病之病友認識","依據病人狀況，主動收集相關檢體送檢","開立病人的治療飲食","A",null,[],"本題考點是入院護理的優先順序與護理業務範圍。入院護理的核心任務是建立基準資料,先完成身體評估與病史詢問,才能據以擬定護理計畫、辨識風險並作為後續變化的比較基準,故 A 最適當。B 未經病人同意即介紹罹患相同疾病的病友認識,違反保密原則,且此時診斷尚未確立,可能加深焦慮與錯誤預期。C 採集檢體送檢屬須有醫囑的醫療行為,護理師不得自行決定檢驗項目。D 開立治療飲食屬醫師處方權範圍,護理師負責執行、監測與飲食衛教而非開立,故選 A。","入院護理可用一條時序記:先安置與環境介紹,再身體評估與病史收集,接著填寫入院護理評估表建立基準值,最後完成入院衛教與護理計畫。此處的邏輯是護理過程五步驟的第一步就是評估,沒有評估資料的計畫必然懸空。肺部電腦斷層出現陰影的情境,病人多處於診斷未明的高度不確定期,心理層面的護理重點是提供可預期的檢查流程資訊以降低焦慮,而不是替他安排病友交流。護理與醫療的業務界線是這類題的固定考點:檢體採集、治療飲食、藥物與檢查皆須醫囑;護理師可獨立執行的是評估、衛教、舒適與安全措施。",[25,27,29,31,34],{"term":26,"count":11},"入院護理",{"term":28,"count":11},"保密原則",{"term":30,"count":11},"護理業務範圍",{"term":32,"count":33},"護理過程評估階段",1,{"term":35,"count":33},"基準資料收集",[37,41,46,51,56,61],{"webId":38,"stem":39,"number":40,"year":10,"session":11},"nurse-115-2-fundamental-nursing-034","協助病人抽取靜脈血液檢體送檢之敘述，下列何者正確？",34,{"webId":42,"stem":43,"number":44,"year":45,"session":33},"nurse-106-1-fundamental-nursing-080","病人抱怨的次數是屬於平衡計分卡（BSC）中之那一種構面？",80,106,{"webId":47,"stem":48,"number":49,"year":50,"session":33},"nurse-107-1-fundamental-nursing-014","王先生 48 歲大腸癌術後第二天，目前呈現以下訊息：①腸蠕動 15 次\u002F分 ②臉色蒼白 ③家屬說：「痛到都沒睡」 ④體溫 39℃ ⑤主訴：「我口好渴」。請問那些是屬於客觀資料？",14,107,{"webId":52,"stem":53,"number":54,"year":55,"session":33},"nurse-108-1-fundamental-nursing-052","有關血液培養（blood culture）之血液採集過程，下列敘述何者正確？",52,108,{"webId":57,"stem":58,"number":59,"year":60,"session":11},"nurse-109-2-fundamental-nursing-016","下列護理評估，何者屬於客觀資料（objective data）？",16,109,{"webId":62,"stem":63,"number":64,"year":65,"session":11},"nurse-110-2-fundamental-nursing-050","醫囑每 2 小時間歇管灌食的病人，已於 8：00 am 灌食 250 mL 後，於 10：00 am 管灌前反抽鼻胃管有 150 mL 之未消化液，下列處置何者最適當？",50,110,"2026-08-06",1787299031805]