# 一名護理師為65歲上腹部開腹術後恢復病人指導預防術後無氣肺。下列何者應納入指導?(複選)

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=zh-tw  
> language: zh-TW  
> subject: System-Specific Assessments  
> category: ROR

## 題目

一名護理師為65歲上腹部開腹術後恢復病人指導預防術後無氣肺。下列何者應納入指導?(複選)

1

深呼吸或咳嗽前以枕頭支撐腹部傷口

2

每2小時翻身、咳嗽、深呼吸(TCDB)

3

為傷口癒合,前48小時臥床休息

4

醫囑允許後盡早於走廊步行

5

清醒時每小時使用激勵呼吸計10次

## 解析

術後無氣肺預防以肺擴張與早期活動為核心。激勵呼吸計、咳嗽前支撐傷口、每2小時TCDB、早期下床均促進肺泡張開與分泌物清除。前48小時臥床錯誤,因不動會惡化無氣肺、增加DVT風險並延遲恢復。

## 深入解析

臨床判斷
無氣肺預防組合: 激勵呼吸計每小時10次、支撐咳嗽、每2小時TCDB、早期下床。避免長時間臥床。上腹部開腹因疼痛限制吸氣風險最高。適當止痛與呼吸計衛教提升順從性。

記憶口訣
無氣肺預防: 呼吸計+支撐+TCDB+下床

韓 vs 美
ERAS(術後加速復原)流程於美歐臺韓皆強調多模式非類鴉片止痛與早期下床。臺灣ERAS路徑亦採與美國同樣的呼吸計與TCDB時程。

## 臨床情境

臨床指引
術後肺照護組合:
- 激勵呼吸計清醒時每小時呼吸10次;設備上標示目標容量
- 支撐咳嗽: 將枕頭抱緊傷口
- 每2小時TCDB(翻身、咳嗽、深呼吸)
- 早期下床: 24小時內下床,逐漸增加距離
- 疼痛控制足以深呼吸
- 監測無氣肺徵象: 發燒 >38、呼吸快、肺音減弱、囉音、低氧

注意
無氣肺為最常見術後肺併發症,可於48-72小時內進展為肺炎。上腹部與胸部手術病人每班聽診肺音。

## 重要概念

- **無氣肺** — 肺泡塌陷導致氣體交換降低。術後原因: 疼痛致淺呼吸、不動、麻醉影響。徵象: 術後24-48小時內發燒、呼吸快、肺底部肺音減弱、囉音、低氧。
- **激勵呼吸計** — 促進深吸氣以擴張肺泡與清除分泌物之手持裝置。目標容量標示在裝置上。術後清醒時每小時呼吸10次。最大吸氣時持續3-5秒。
- **早期下床** — 若無禁忌應於24小時內開始之術後標準介入。促進肺擴張、腸蠕動、預防DVT、加速恢復。為ERAS流程之一。先坐再站,再短距離行走。

## 相同主題題目

- [A nurse on a medical-surgical unit reviews the morning labs for a 67-year-old male client …](https://mymerci.kr/pages/nclex_q.php?qn_id=361711&lang=zh-tw)
- [A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following ton…](https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=zh-tw)
- [A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit…](https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=zh-tw)
- [A 72-year-old male client is receiving a continuous IV heparin infusion for a left lower-e…](https://mymerci.kr/pages/nclex_q.php?qn_id=362064&lang=zh-tw)
- [A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=363990&lang=zh-tw)
- [A nurse is conducting morning rounds on adult medical-surgical clients. Which clients shou…](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=zh-tw)
- [A nurse is administering a unit of packed red blood cells to a client. Twenty minutes afte…](https://mymerci.kr/pages/nclex_q.php?qn_id=364947&lang=zh-tw)
- [A nurse is evaluating a 35-year-old client during a routine outpatient visit 4 years after…](https://mymerci.kr/pages/nclex_q.php?qn_id=368098&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_