— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正給予華法林（warfarin）。病人的 INR 為 4.0。處方劑量為每日 5 mg。護理師應採取何項措施？
A nurse is administering warfarin. The client's INR is 4.0. The prescribed dose is 5 mg daily. The nurse should take which action?
- AAdminister the prescribed dose and document.給予處方劑量並記錄。
- BAdminister half the prescribed dose and notify the physician.給予處方劑量的一半並通知醫師。
- CAdminister the prescribed dose and monitor for bleeding.給予處方劑量並監測出血情形。
- DHold the dose and notify the physician.✓ 正解暫停給藥並通知醫師。
— Explanation · 中文詳解 —
華法林（Warfarin）的治療監測指標為國際標準化比值（INR）。對於大多數適應症，治療範圍為 2.0-3.0，若 INR 達到 4.0，表示血液過度稀釋，出血風險大幅增加。護理師此時必須採取「安全優先」原則：暫停給藥並通知醫師，由醫師評估是否需減量或使用維生素 K（Vitamin K）進行拮抗。
The therapeutic monitoring parameter for warfarin is the International Normalized Ratio (INR). For most indications, the therapeutic range is 2.0-3.0. An INR of 4.0 indicates excessive anticoagulation and substantially increased bleeding risk. The nurse must follow the 'safety first' principle: hold the dose and notify the physician, who will evaluate whether to reduce the dose or administer Vitamin K as an antidote.