— 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。