— 藥理與非經腸給藥 · HARD · MCQ —
護理師準備給予心房顫動病人 Warfarin，該病人目前 INR 值為 4.5。護理師應採取哪項行動？
A nurse is preparing to administer warfarin to a client with atrial fibrillation. The client's current INR is 4.5. Which action is appropriate for the nurse to take?
- AAdminister the dose as ordered按指示給藥
- BHold the dose and notify the healthcare provider✓ 正解暫停給藥並通知醫療提供者
- CIncrease the dosage of warfarin增加華法林劑量
- DAdminister Vitamin K orally口服維生素K
— Explanation · 中文詳解 —
治療性 INR 範圍通常在 2.0-3.0 之間。該病人 INR 為 4.5，處於高抗凝血風險狀態，出血機率大幅增加。護理師應先暫停給藥並回報醫師，由醫師評估是否減量或採取其他措施，而非自行投藥或更改醫囑。
The therapeutic INR range is generally between 2.0 and 3.0. An INR of 4.5 places the client at high risk for anticoagulation-related bleeding. The nurse should first hold the medication and notify the physician, who will determine whether to reduce the dose or take other actions, rather than administering the drug or modifying orders independently.
✦ 台美臨床差異
美台臨床對於 INR 超標的處理標準一致，皆以暫停給藥並通報作為標準流程。