NurslixJournal
降低風險 · MEDIUM · SATA

護理師準備給予一位心衰竭病人毛地黃(Digoxin),哪些發現應讓護理師停止給藥?(選所有適合的)

A nurse is preparing to administer digoxin to a client with heart failure. Which findings require the nurse to hold the medication? (Select all that apply.)

  • AApical heart rate of 52 beats per minute✓ 正解
    心尖心率每分鐘 52 下
  • BPotassium level of 3.2 mEq/L✓ 正解
    鉀離子濃度 3.2 mEq/L
  • CYellow-green halos seen around lights✓ 正解
    看燈光時出現黃綠色光暈
  • DBlood pressure of 130/80 mmHg
    血壓 130/80 mmHg
  • EDigoxin level of 1.2 ng/mL
    地高辛濃度 1.2 ng/mL
Explanation · 中文詳解

毛地黃中毒風險高。心跳 < 60 bpm 需停藥;低血鉀(<3.5 mEq/L)會顯著增加毛地黃毒性;視覺異常(如黃綠色光暈)是中毒的特徵性症狀。選項 D 為正常血壓,無需停藥;選項 E 的濃度 1.2 ng/mL 在治療範圍內(0.5-2.0 ng/mL),不必停藥。

The nurse must hold digoxin if the apical heart rate is below 60 beats per minute, as bradycardia indicates potential toxicity. Additionally, hypokalemia (potassium <3.5 mEq/L) increases the risk of digoxin toxicity, and visual disturbances like yellow-green halos are classic signs of an overdose.

✦ 台美臨床差異

美國護理師給藥前評估完整,特別是 Apical pulse 測量;台灣臨床多由護理師觀察心電圖監測儀,評估流程相似。

Related · 同分類的其他題目

More from Reduction of Risk Potential

瀏覽全部 1,953 題 降低風險 →
Jump to another chapter