— 降低風險 · EASY · MCQ —
護理師準備為病人服用毛地黃（Digoxin）。給藥前哪項行動是必要的？
A nurse is preparing to administer digoxin to a client. Which action is essential before administering the medication?
- AVerify the client's potassium level is elevated確認病人的血鉀濃度升高
- BMeasure the apical heart rate for one full minute✓ 正解測量心尖脈搏整整一分鐘
- CAssess the client's respiratory rate評估病人的呼吸速率
- DCheck the client's blood pressure檢查病人的血壓
— Explanation · 中文詳解 —
毛地黃具有負性變時作用（減慢心率）。為預防藥物過量導致嚴重的心搏過緩，給藥前必須確實測量心尖脈（apical pulse）整整一分鐘。若心率過低（成人通常 <60 bpm），則須暫停給藥並通知醫師。這是確保病人用藥安全、防止毛地黃中毒的基本護理評估。
Digoxin has a negative chronotropic effect, meaning it slows the heart rate. Before administration, the nurse must measure the apical pulse for one full minute to assess for bradycardia. If the heart rate is below the specified threshold (typically 60 bpm for adults), the medication should be withheld to prevent toxicity.
✦ 台美臨床差異
兩地護理標準一致，但在電子病歷紀錄上，台灣常要求在給藥系統標註心跳數。