一位新畢的註冊護理師正在給藥。護理師準備給予心臟衰竭病患常規劑量的地高辛 (digoxin)。病患的心尖脈搏為每分鐘 52 下。護理師最恰當的行動為何？
A newly graduated registered nurse is administering medications. The nurse prepares to give a scheduled dose of digoxin to a client with heart failure. The client's apical pulse is 52 beats per minute. What is the most appropriate action by the nurse?
- AHold the scheduled dose of digoxin and notify the primary healthcare provider.✓ 正解暫停預定的地高辛劑量並通知主要醫療保健提供者。
- BWait thirty minutes, reassess the apical pulse, and then administer the dose.等待三十分鐘，重新評估心尖脈搏，然後給藥。
- CAdminister the routine dose of digoxin and document the client's current heart rate.給予常規劑量的地高辛並記錄病人目前的心率。
- DAdminister a half dose of the medicine to prevent severe further bradycardia.給予半劑量藥物以防止嚴重的心動過緩。
本題測驗危險藥物的給藥指引與優先處置。地高辛 (Digoxin) 是一種強心劑，具有減慢心跳的強烈副作用，且治療指數極窄，非常容易中毒。護理金律規定，在給予成人 digoxin 之前，必須測量整整一分鐘的心尖脈 (apical pulse)。如果成人的心跳低於每分鐘 60 下 (bradycardia)，護理師必須『扣留藥物 (hold the dose)』並通知醫師。選項 A 正確。給予藥物 (選項 C) 會導致心跳進一步下降並可能引發致死性心律不整。選項 B 延誤處置。選項 D 護理師無權自行更改藥物劑量。
This question tests the administration guidelines and prioritization for a high-risk medication. Digoxin is a cardiac glycoside with strong negative chronotropic effects and a very narrow therapeutic index, making toxicity easy to develop. A nursing rule states that before administering digoxin to an adult, the apical pulse must be measured for a full minute. If the adult's heart rate is below 60 beats per minute (bradycardia), the nurse must hold the dose and notify the provider. Option A is correct. Administering the drug (option C) would further decrease the heart rate and may precipitate fatal dysrhythmia. Option B unnecessarily delays intervention. In option D, the nurse does not have the authority to unilaterally alter the prescribed dose.
Digoxin 的 60下心跳底線是全球通用的護理絕對鐵律。