— 藥理與非經腸給藥 · HARD · SATA —
護理師準備發藥給多位病人，哪一位需要立即介入？（選所有適合的）
A nurse is preparing to administer medications to multiple clients. Which client requires immediate intervention by the nurse? (Select all that apply.)
- AA client on warfarin with an INR of 4.5✓ 正解服用華法林且 INR 為 4.5 的病人
- BA client on morphine reporting nausea服用嗎啡並主訴噁心的病人
- CA client on metformin with a scheduled CT scan with contrast✓ 正解服用二甲雙胍且預約進行含顯影劑電腦斷層掃描的病人
- DA client on insulin lispro with a blood glucose of 70 mg/dL✓ 正解服用胰島素 lispro 且血糖為 70 mg/dL 的病人
- EA client on lisinopril reporting a dry cough服用 lisinopril 並主訴乾咳的病人
— Explanation · 中文詳解 —
A：INR 4.5 遠高於治療範圍（通常 2-3），出血風險極高。C：Metformin 與顯影劑併用可能引發乳酸中毒，需暫停用藥。D：70 mg/dL 處於低血糖邊緣，需立即進食或處理。B 為鴉片類藥物常見副作用，非立即生命危險。E 的乾咳是 ACEI 常見的持續性副作用，需報告但非急迫。
Immediate intervention is required for clients with a dangerously elevated INR indicating high bleeding risk, those taking metformin prior to contrast imaging due to lactic acidosis risk, and those experiencing hypoglycemia. Nausea from morphine and dry cough from lisinopril are expected side effects that do not require emergency intervention.
✦ 台美臨床差異
此類藥物安全監測在台美護理實務中均為核心知識，對於高風險警示值的處置邏輯一致。