# 一位服用 warfarin 的病人 INR 值為 5.8，並主訴有黑色、瀝青樣糞便。護理師應首先採取哪一項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397253&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

一位服用 warfarin 的病人 INR 值為 5.8，並主訴有黑色、瀝青樣糞便。護理師應首先採取哪一項行動？

## 選項

1. 暫停給予 warfarin 並立即通知醫師。 **✔ 正確答案**
2. 隨大量餐點給予下一次劑量。
3. 告訴病人服用 warfarin 時出現深色糞便是正常的。
4. 鼓勵用力刷牙以評估牙齦出血。

**正確答案: 1**

## 解析

INR 值升高伴隨黑色、瀝青樣糞便，暗示可能有腸胃道出血和過度抗凝。護理師應根據方案暫停給予 warfarin 並立即通知醫師。繼續給藥或忽略出血線索是不安全的。

## 深入解析

臨床判斷
利用病人線索、時間點、檢驗數據和安全風險，選擇最符合 Warfarin 出血疑慮的回應。

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，而非孤立的回憶。

## 臨床情境

臨床實務指引
對於 Warfarin 出血疑慮，請將完整的線索模式與病人當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意事項
當完整情境改變了優先順序或安全性時，不要僅根據單一孤立的線索選擇行動。

## 重要概念

- **Warfarin** — 一種需要監測凝血效果的口服抗凝血劑。
- **INR** — 用於監測 warfarin 抗凝效果的實驗室檢驗指標。
- **黑便** — 可能表示腸胃道出血的黑色、瀝青樣糞便。

## 相同主題題目

- [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw)
- [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw)
- [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw)
- [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw)
- [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw)
- [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw)
- [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw)
- [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=397253&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=397253&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=397253&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=397253&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=397253&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。_