# 一位服用 digoxin 的個案主訴噁心且看到黃色光暈。心尖脈搏為 48 次/分。護理師應採取何項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396585&lang=zh-tw  
> language: zh-TW  
> subject: Medication Administration  
> category: PPT

## 題目

一位服用 digoxin 的個案主訴噁心且看到黃色光暈。心尖脈搏為 48 次/分。護理師應採取何項行動？

## 選項

1. 給予劑量，因為噁心與 digoxin 無關。
2. 暫停給藥並通知醫師。 **✔ 正確答案**
3. 給予額外劑量以提高脈搏速率。
4. 鼓勵飲用葡萄柚汁以改善吸收。

**正確答案: 2**

## 解析

噁心、視覺變化和心搏過緩需注意 digoxin 中毒。護理師應根據方案暫停給藥並通知醫師。給予額外的 digoxin 或忽略症狀是不安全的。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗值和安全風險，選擇最符合 Digoxin 中毒的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的回憶。

## 臨床情境

臨床實務指引
對於 Digoxin 中毒，將完整的線索模式與個案當前的穩定性、醫囑資料和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據一個單獨的線索選擇行動。

## 重要概念

- **Digoxin** — 一種強心苷，用於特定的心衰竭或心律狀況。
- **心搏過緩** — 心率低於臨床情境的預期值。
- **藥物中毒** — 因藥物濃度過高或敏感性增加所引起的有害效應。

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