護理師正在照顧一位因心房顫動接受華法林（Warfarin）治療的病人。實驗室報告顯示其國際標準化比值（INR）為 5.0。護理師應首先採取哪項行動？
A nurse is caring for a client receiving warfarin for atrial fibrillation. The laboratory report shows an International Normalized Ratio (INR) of 5.0. Which action should the nurse take first?
- APrepare to administer Vitamin K via intramuscular injection準備以肌肉注射方式給予維生素 K
- BAdminister the next dose of warfarin as scheduled按原定計畫給予下一劑華法林
- CHold the next dose of warfarin and notify the provider✓ 正解暫停給予下一劑華法林並通知醫師
- DAssess the client for signs of abnormal bleeding評估病人是否有異常出血跡象
華法林治療的標準 INR 範圍通常在 2.0 至 3.0 之間。當 INR 達到 5.0 時，表示病人處於極高的出血風險中，屬於治療窗外的異常值。根據護理優先原則，首先應暫停可能導致危害的藥物（Hold the dose）並通知醫師以獲取進一步處置指令。評估出血（D）雖然重要，但在發現數值嚴重偏離時，停止致病源並與醫療團隊溝通是首要的安全介入。維生素 K（A）通常在 INR > 10 或有活動性出血時才考慮，且通常不建議肌肉注射，因為容易導致血腫。
The standard therapeutic INR range for warfarin is generally 2.0 to 3.0. When the INR reaches 5.0, the patient is at very high risk of bleeding — well outside the therapeutic window. Following nursing priority principles, the nurse should first hold any further doses of the offending medication and notify the physician for further orders. Assessing for bleeding (D) is important, but when the laboratory value is markedly abnormal, halting the causative agent and communicating with the medical team is the priority safety intervention. Vitamin K (A) is generally considered only when the INR is > 10 or with active bleeding, and intramuscular injection is not recommended because of the risk of hematoma.
在美國，許多醫院設有抗凝血治療協議（Anticoagulation Protocols），護理師可在數值異常時先 Hold 藥再通知；台灣則多需先口頭報告醫師後由其開立停藥醫囑。