— 藥理與非經腸給藥 · EASY · MCQ —
護理師正為一位心臟衰竭病人給予地高辛(Digoxin)。下列哪項評估結果需要護理師暫停給藥?
A nurse is administering digoxin to a patient with heart failure. Which assessment finding requires the nurse to withhold the medication?
- ABlood pressure of 110/70 mmHg血壓 110/70 mmHg
- BSerum potassium level of 4.0 mEq/L血清鉀濃度 4.0 mEq/L
- CApical pulse of 52 bpm✓ 正解心尖脈搏 52 bpm
- DRespiratory rate of 18 breaths/min呼吸頻率 18 breaths/min
— Explanation · 中文詳解 —
地高辛(Digoxin)具有正性肌力與負性頻率作用,能增強心肌收縮力並減慢房室結傳導。其治療窗窄,極易發生中毒。給藥前最重要的護理評估是測量心尖脈(Apical pulse),若成人心跳低於 60 bpm,給藥可能導致嚴重心搏過緩或心律不整。若病人出現噁心、嘔吐、視力模糊(黃綠色視覺)等中毒徵兆,也應立即停藥並通知醫師。
The nurse must withhold digoxin if the apical pulse is below 60 beats per minute, as the medication slows heart rate and bradycardia can lead to serious complications. Other findings such as a stable blood pressure, normal serum potassium, and normal respiratory rate do not require withholding the medication.