— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師準備給予深層靜脈栓塞病人華法林（Warfarin）。病人 INR 值為 3.5。護理師應優先採取的行動為何？
A nurse is preparing to administer warfarin to a client with a history of deep vein thrombosis. The client's INR is 3.5. What is the priority nursing action?
- AHold the dose and notify the provider✓ 正解暫停給藥並通知醫師
- BIncrease the dose to compensate for clots增加劑量以對抗血栓
- CAdminister Vitamin K subcutaneously皮下給予維生素 K
- DAdminister the dose as scheduled按時程給予劑量
— Explanation · 中文詳解 —
一般華法林治療範圍的目標 INR 約在 2.0 至 3.0 之間（視適應症而定）。當數值達到 3.5 時，代表出血風險顯著增加，此時給藥並不安全。正確做法是暫停給藥並向醫師回報，等待醫囑決定是否調整劑量或進行後續觀察，避免病人因過度抗凝血導致出血。
An INR of 3.5 exceeds the typical therapeutic range of 2.0 to 3.0, indicating an increased risk of hemorrhage due to over-anticoagulation. The priority nursing action is to hold the warfarin dose and notify the provider to prevent further elevation of the INR and assess for necessary interventions.
✦ 台美臨床差異
台灣許多醫院有針對 INR 過高的自動化護理流程，但最終決定權多仍在醫師手中。