# 一位有端坐呼吸的個案，將接受腸道灌食，床頭抬高30–45度。在監督下的擺位試驗中，護理師同時監測血壓。請點選符合指定角度且在不造成低血壓下，有最佳血氧紀錄的姿勢。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=581206&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

一位有端坐呼吸的個案，將接受腸道灌食，床頭抬高30–45度。在監督下的擺位試驗中，護理師同時監測血壓。請點選符合指定角度且在不造成低血壓下，有最佳血氧紀錄的姿勢。

![](https://mymerci.kr/data/nclex/hotspot/regen_20260908_2350/HSR543.svg)

## 解析

C為40度，SpO2 96%，且血壓維持穩定。

## 深入解析

快速解答
C. C為40度，SpO2 96%，且血壓維持穩定。
為何這是最佳選擇
請對照參考線讀取角度，然後同時比較血氧與血壓。單獨最高的血氧飽和度並非最佳選擇，因為該姿勢超出指定範圍且造成低血壓。
臨床情境
這些觀察數據為虛構的教學資料。請應用所述情境；所選特徵本身不能取代完整的床邊評估。
記憶口訣
選擇符合照護計畫及個案耐受度的姿勢。
決策原則
選擇符合照護計畫及個案耐受度的姿勢。
為何其他區域不合適
A低於30度。B在範圍內，但血氧飽和度低於C，且血壓相似。D血氧飽和度最高，但超過45度且血壓降至86/50。
**資料來源**
- 腸道灌食時抬高床頭是預防吸入的一部分；本案例明確指定角度。

## 重要概念

- **Position angle and competing hemodynamic response** — 選擇符合照護計畫及個案耐受度的姿勢。
- **Comparison with context** — 若僅考慮血氧飽和度，D看似最佳，但不符合其他兩項條件。

## 相同主題題目

- [A patient with cirrhosis and grade 2 hepatic encephalopathy has been started on lactulose.…](https://mymerci.kr/pages/nclex_q.php?qn_id=372852&lang=zh-tw)
- [A 78-year-old with end-stage pancreatic cancer is admitted to the medical ward. After revi…](https://mymerci.kr/pages/nclex_q.php?qn_id=372916&lang=zh-tw)
- [A patient is in the active dying phase from end-stage heart failure. Family members are at…](https://mymerci.kr/pages/nclex_q.php?qn_id=373259&lang=zh-tw)
- [A nurse is caring for an immobile, malnourished older adult at high risk for pressure inju…](https://mymerci.kr/pages/nclex_q.php?qn_id=373515&lang=zh-tw)
- [A patient is post-op day 0 from a transurethral resection of the prostate (TURP) with a th…](https://mymerci.kr/pages/nclex_q.php?qn_id=374201&lang=zh-tw)
- [A 6-year-old is admitted with newly diagnosed nephrotic syndrome: proteinuria 4+, serum al…](https://mymerci.kr/pages/nclex_q.php?qn_id=374922&lang=zh-tw)
- [A nurse is caring for a postpartum patient who has saturated 2 perineal pads in 30 minutes…](https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=zh-tw)
- [A nurse is implementing trauma-informed care for a client with a history of intimate partn…](https://mymerci.kr/pages/nclex_q.php?qn_id=374978&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=581206&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=581206&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=581206&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=581206&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=581206&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。_