— 降低風險 · HARD · MCQ —
護理師準備給予病人 Digoxin 時，哪項評估結果應導致護理師暫停給藥？
A nurse is preparing to administer digoxin to a client. Which assessment finding should lead the nurse to hold the medication?
- AClient reports mild nausea病人主訴輕微噁心
- BApical heart rate of 54 beats per minute✓ 正解心尖心率每分鐘54次
- CBlood pressure of 110/70 mmHg血壓110/70 mmHg
- DPotassium level of 4.2 mEq/L鉀離子濃度4.2 mEq/L
— Explanation · 中文詳解 —
Digoxin 具負性變時作用（Negative Chronotropic），若成人心搏速率低於 60 次/分，則有發生嚴重心動過緩的風險。給藥前需執行完整的 1 分鐘心尖脈測量，若小於標準數值則需暫停並回報醫師。
Digoxin has a negative chronotropic effect, so the nurse must hold the medication if the apical heart rate is below 60 beats per minute to prevent severe bradycardia. Mild nausea is a common symptom but not a priority contraindication, while normal blood pressure and potassium levels do not require withholding the dose.
✦ 台美臨床差異
台美給藥前評估標準一致，但美國護理師更常在病歷記錄中強調與醫師討論劑量調整。