# 一名心衰竭高齡個案預定給予 digoxin。心尖脈搏 54 次/分且不規則，個案表示噁心並看到黃色光暈。護理師應怎麼做？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=zh-tw  
> language: zh-TW  
> subject: Medication Administration  
> category: PPT

## 題目

一名心衰竭高齡個案預定給予 digoxin。心尖脈搏 54 次/分且不規則，個案表示噁心並看到黃色光暈。護理師應怎麼做？

## 選項

1. 暫停 digoxin 並通知醫療人員。 **✔ 正確答案**
2. 給予 digoxin，30 分鐘後再測脈搏。
3. 與食物一起給予 digoxin 以減少噁心。
4. 只確認橈動脈脈搏後給予 digoxin。

**正確答案: 1**

## 解析

心尖脈搏低於 60 次/分、不規則、噁心與黃色光暈提示可能 digoxin 毒性或不安全給藥。護理師應暫停藥物並通知醫療人員。繼續給藥或只依賴橈動脈脈搏可能加重心搏過慢與毒性。

## 深入解析

臨床判斷
給高風險心臟藥前，同時判斷給藥參數與毒性線索。

記憶重點
Digoxin：心尖脈搏完整 1 分鐘，低脈搏暫停，注意光暈與噁心。

## 臨床情境

實務指引
Open RN 藥理指引指出，digoxin 前應完整測量心尖脈搏 1 分鐘，毒性徵象包括心搏過慢、噁心、視覺光暈與心律不整。

注意
不要只因為到了給藥時間就給 digoxin。

## 重要概念

- **Digoxin** — 用於部分心衰竭或心房顫動個案的強心配醣體；毒性可造成心搏過慢、噁心、光暈與心律不整。
- **心尖脈搏** — 在心尖部聽診的心率，給 digoxin 等藥物前需完整計數 1 分鐘。
- **心搏過慢** — 成人常指心率低於 60 次/分，給會降低心率的藥物前需評估。

## 相同主題題目

- [An older adult with heart failure is scheduled to receive digoxin. The apical pulse is 54/…](https://mymerci.kr/pages/nclex_q.php?qn_id=393663&lang=zh-tw)
- [A hospitalized client has a blood glucose of 118 mg/dL and is prescribed rapid-acting insu…](https://mymerci.kr/pages/nclex_q.php?qn_id=393722&lang=zh-tw)
- [A client taking lithium reports vomiting, coarse hand tremors, and new confusion. Which ac…](https://mymerci.kr/pages/nclex_q.php?qn_id=394021&lang=zh-tw)
- [A client taking lithium reports vomiting, coarse hand tremors, and new confusion. Which ac…](https://mymerci.kr/pages/nclex_q.php?qn_id=394022&lang=zh-tw)
- [A client arrives at the emergency department 2 hours after taking a large amount of acetam…](https://mymerci.kr/pages/nclex_q.php?qn_id=394049&lang=zh-tw)
- [A postoperative client who received IV morphine is difficult to arouse. Respirations are 7…](https://mymerci.kr/pages/nclex_q.php?qn_id=394070&lang=zh-tw)
- [A client uses an albuterol inhaler for wheezing and asks what side effect may occur. Which…](https://mymerci.kr/pages/nclex_q.php?qn_id=394106&lang=zh-tw)
- [The nurse teaches a client about insulin glargine. Which statement by the client indicates…](https://mymerci.kr/pages/nclex_q.php?qn_id=394115&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_