護理師欲給予心衰竭病人口服 digoxin 0.25 mg。給藥前測量心尖脈搏為每分鐘 52 下。護理師應優先採取何種行動？
A nurse is administering digoxin 0.25 mg orally to a client with heart failure. Before administration, the nurse checks the apical pulse and finds it to be 52 beats per minute. What is the priority nursing action?
- AWithhold the dose and notify the primary healthcare provider✓ 正解暫停劑量並通知主要醫療保健提供者
- BRetake the pulse in 30 minutes to see if it increases30分鐘後重新測量脈搏，以觀察是否上升
- CAdminister the medication as scheduled按預定時間給藥
- DAdminister the medication and monitor for palpitations給藥並監測心悸
Digoxin 具有負性變時作用，若心跳過慢（成人小於 60 bpm）可能導致嚴重毒性反應。標準操作程序為暫停給藥並回報醫師，以防藥物過量導致心律不整或心跳停止。不可自行等待脈搏恢復或無視心跳過低風險給藥。
Digoxin has a negative chronotropic effect; if the heart rate is too slow (below 60 bpm in adults), administration may cause serious toxicity. The standard procedure is to hold the dose and notify the provider, in order to prevent drug-induced dysrhythmia or cardiac arrest. The nurse must not simply wait for the pulse to recover or administer the medication despite the bradycardia.
台美臨床對於 digoxin 給藥警戒值均為 60 bpm，但台灣醫師若有特殊醫囑則需遵照醫囑執行。