# 一位髖關節手術後服用直接口服抗凝血劑的個案變得虛弱和頭暈。血壓為 82/48 mm Hg，腹部緊繃且脹大。哪項行動是優先考量？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397284&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

一位髖關節手術後服用直接口服抗凝血劑的個案變得虛弱和頭暈。血壓為 82/48 mm Hg，腹部緊繃且脹大。哪項行動是優先考量？

## 選項

1. 啟動快速評估以檢查可能的內出血。 **✔ 正確答案**
2. 鼓勵個案行走以改善循環。
3. 提早給予下一次抗凝血劑劑量。
4. 提供高纖維點心並於明天重新評估。

**正確答案: 1**

## 解析

服用抗凝血劑的個案出現低血壓、頭暈、虛弱和腹部脹大，暗示可能的內出血和休克。優先事項是緊急評估和介入。下床活動、額外給予抗凝血劑或延遲重新評估都是不安全的。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，選擇最符合服用抗凝血劑可能內出血的反應。

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
對於服用抗凝血劑可能內出血，將完整的線索模式與個案當前的穩定性、醫囑數據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，不要僅根據一個孤立的線索選擇行動。

## 重要概念

- **Direct Oral Anticoagulant** — 一種口服藥物，可減少血栓形成，無需常規 INR 監測。
- **Internal Bleeding** — 體內出血，可能導致休克或器官受損。
- **Shock** — 組織灌流不足，可能危及生命。

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