[{"data":1,"prerenderedAt":66},["ShallowReactive",2],{"q-nurse-115-2-medical-surgical-035":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":36,"lastmod":65},"內外科護理學","medical-surgical",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-115-2-內外科護理學-035","nurse-115-2-medical-surgical-035",115,2,35,"有關肺栓塞病人護理措施之敘述，下列何者最不適當？",{"A":14,"B":15,"C":16,"D":17},"開刀無法早期下床活動的病人，應時常協助翻身促進血液循環","服用 warfarin（Coumadin ® ）病人，應避免食用大量芹菜","教導病人，應穿著緊繃衣物，以保暖及促進血液循環","教導病人，儘量避免交叉雙腿、翹二郎腿或膝跪太久的動作","C",null,[],"本題考點是肺栓塞與深層靜脈栓塞的預防原則。依靜脈回流機轉,預防重點在避免血流停滯與局部受壓,醫用漸進式壓力襪由遠端向近端遞減壓力有助回流,但一般緊繃衣物會不均勻壓迫下肢與腹部靜脈,反而阻礙回流並增加血栓形成風險,故 C 最不適當。A 適當,無法早期下床者以定時翻身、被動關節運動與踝泵運動促進循環。B 適當,warfarin 為維生素 K 拮抗劑,大量攝取富含維生素 K 的深綠色蔬菜會削弱抗凝血效果,原則是攝取量維持穩定。D 適當,交叉雙腿、翹二郎腿與久跪都造成局部靜脈受壓與血流停滯。","延伸原理:血栓形成依 Virchow 三要素——血流停滯、血管內皮損傷、血液高凝狀態,術後臥床同時具備前兩項,懷孕、口服避孕藥、惡性腫瘤與脫水則加重第三項,護理措施就是逐項拆解這三要素。warfarin 監測用凝血酶原時間與國際標準化比值,作用受飲食維生素 K 與眾多藥物干擾;肝素類則以部分凝血活酶時間監測,兩者常在治療初期重疊使用,因為 warfarin 需數日才達穩定抗凝效果。肺栓塞的典型組合是突發呼吸困難、胸痛與心跳過快,合併低血氧但胸部影像早期可能無明顯變化。可連結概念:D-dimer 判讀限制、預防性抗凝、靜脈血栓後症候群。",[24,27,30,32,34],{"term":25,"count":26},"Virchow 三要素",5,{"term":28,"count":29},"靜脈血流停滯",1,{"term":31,"count":29},"維生素 K 拮抗劑",{"term":33,"count":29},"漸進式壓力襪原理",{"term":35,"count":29},"深層靜脈栓塞預防",[37,41,45,50,55,60],{"webId":38,"stem":39,"number":40,"year":9,"session":10},"nurse-115-2-medical-surgical-036","下列何者是急性呼吸窘迫症候群（ARDS）早期的重要徵象？",36,{"webId":42,"stem":43,"number":10,"year":44,"session":10},"nurse-106-2-medical-surgical-002","林先生手術移除額葉腦腫瘤後返回神經外科加護單位觀察，病人突然全身性抽搐，下列措施何者不適當？",106,{"webId":46,"stem":47,"number":48,"year":49,"session":29},"nurse-107-1-medical-surgical-016","急性心肌梗塞最典型的臨床表徵，下列何者正確？",16,107,{"webId":51,"stem":52,"number":53,"year":54,"session":29},"nurse-108-1-medical-surgical-054","針對左側氣胸病人之患側胸部評估，下列何者為最可能之發現？",54,108,{"webId":56,"stem":57,"number":58,"year":59,"session":10},"nurse-109-2-medical-surgical-018","有關骨性關節炎的診斷檢查，下列何者正確？",18,109,{"webId":61,"stem":62,"number":63,"year":64,"session":10},"nurse-110-2-medical-surgical-052","當動脈氣體分析值為 pH：7.40、PaCO 2 ：42 mmHg、HCO 3 - ：24 mEq\u002FL、PaO 2 ：80 mmHg 時，有關病人呼吸器脫離（ventilator weaning）的敘述，下列何者正確？",52,110,"2026-08-06",1787299037251]