— 生理適應 · MEDIUM · MCQ —
心衰竭病人正在服用毛地黃(Digoxin)。護理師應優先評估哪項發現?
A client with heart failure is receiving digoxin. Which assessment finding should the nurse prioritize?
- ABlood pressure血壓
- BPeripheral oxygen saturation周邊血氧飽和度
- CRespiratory rate呼吸頻率
- DApical heart rate✓ 正解心尖脈率
— Explanation · 中文詳解 —
地高辛(Digoxin)具有負性變時作用(Negative Chronotropic Effect),會減慢心率。若病人出現緩脈(Bradycardia),可能導致心輸出量不足。因此,在給藥前必須測量心尖脈(Apical pulse)滿一分鐘,若心跳低於每分鐘 60 次,則需暫停給藥並通知醫師,以避免引發致命性心律不整。
Digoxin has a negative chronotropic effect that slows the heart rate, making apical pulse assessment the priority before administration. The nurse must count the apical pulse for one full minute and withhold the medication if the rate is below 60 beats per minute to prevent bradycardia and potential fatal arrhythmias.