— 生理適應 · EASY · MCQ —
心衰竭病人開立了 Digoxin。哪項評估發現要求護理師必須暫停給藥？
A client with heart failure is prescribed digoxin. Which assessment finding would require the nurse to hold the medication?
- ARespiratory rate 20 breaths/min呼吸頻率 20 次/分鐘。
- BBlood pressure 100/60 mmHg血壓 100/60 mmHg。
- CApical pulse 52 beats/min✓ 正解心尖脈搏 52 次/分鐘。
- DPotassium level 4.5 mEq/L鉀離子濃度 4.5 mEq/L。
— Explanation · 中文詳解 —
Digoxin 具負性頻率作用，會減慢心跳。臨床標準規定，若成人心尖脈（Apical pulse）低於 60 次/分，應暫停給藥並通知醫師。血壓 100/60（B）尚在可接受範圍且非 Digoxin 主要監控指標；鉀離子 4.5（D）正常且安全。
Digoxin has a negative chronotropic effect and slows the heart rate. Clinical standards specify that if the adult apical pulse is below 60 beats per minute, the medication should be held and the physician notified. A blood pressure of 100/60 (B) is within an acceptable range and is not a primary monitoring indicator for digoxin; a potassium level of 4.5 (D) is normal and safe.
✦ 台美臨床差異
兩地護理標準一致，皆強調給藥前測量心尖脈一分鐘。