# 服用 warfarin 的個案表示有黑色柏油樣便。INR 為 5.8。護理師首先應做什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393879&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

服用 warfarin 的個案表示有黑色柏油樣便。INR 為 5.8。護理師首先應做什麼？

## 選項

1. 通知醫療人員，並預期可能有暫停或逆轉抗凝的醫囑。 **✔ 正確答案**
2. 將下一劑 warfarin 與食物一起給予以減少胃刺激。
3. 未進一步評估即鼓勵增加富含 vitamin K 的食物。
4. 記錄為預期發現，1 週後再檢查 INR。

**正確答案: 1**

## 解析

黑色柏油樣便合併 INR 顯著升高，提示可能腸胃道出血與抗凝過度。優先是立即通知醫療人員，並準備執行暫停 warfarin 或逆轉治療等醫囑。給下一劑或延後追蹤並不安全。

## 深入解析

臨床判斷
warfarin 加出血徵象是安全警訊，尤其 INR 很高時。

記憶重點
高 INR 加黑便，現在就報告。

## 臨床情境

實務指引
warfarin 需要監測出血與 INR 升高。黑便、異常出血或瘀青需要迅速臨床評估。

注意
不要自行開立 vitamin K；應預期並執行醫囑。

## 重要概念

- **Warfarin** — 降低血栓形成的口服抗凝血藥，需要 INR 監測。
- **INR** — 用於監測 warfarin 效果與出血風險的檢驗值。
- **黑色柏油樣便** — 可能表示腸胃道出血的黑色黏稠糞便。

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