# 一位68歲心房顫動服用warfarin的個案，4天前因泌尿道感染開始使用trimethoprim-sulfamethoxazole。個案主訴手臂和腿部出現新的瘀傷。護理師檢視電子健康紀錄。護理師應首先做什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505807&lang=zh-tw  
> language: zh-TW  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## 題目

一位68歲心房顫動服用warfarin的個案，4天前因泌尿道感染開始使用trimethoprim-sulfamethoxazole。個案主訴手臂和腿部出現新的瘀傷。護理師檢視電子健康紀錄。護理師應首先做什麼？

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心房顫動，每日服用warfarin 5 mg；4天前因UTI開始使用trimethoprim-sulfamethoxazole；主訴手臂和腿部出現新的瘀傷。

血壓128/78 mmHg，心率88次/分，呼吸18次/分，體溫98.6°F (37.0°C)

INR 5.8（治療範圍2.0-3.0），血紅素12.1 g/dL，血小板210,000/mm³

Warfarin 5 mg每日口服；Trimethoprim-sulfamethoxazole DS 1錠每日兩次，共7天；今日檢測PT/INR

個案意識清楚、定向力正常；雙側上下肢多處瘀斑；無活動性出血。

1

暫停下一劑warfarin並通知醫療提供者。

✕

2

依醫囑給予維生素K 2.5 mg口服。

✕

3

採集尿液檢體進行培養和敏感性試驗。

✕

4

在瘀傷處冰敷並抬高肢體。

✕

## 解析

個案的INR為5.8，超出治療範圍，且出現新的瘀傷，顯示出血風險高。優先措施是暫停下一劑warfarin以防止進一步抗凝，並立即通知醫療提供者以獲取進一步醫囑，例如給予維生素K或加強監測。在沒有醫囑的情況下給予維生素K不屬於護理師的執業範圍。採集尿液檢體和冰敷是較低優先級的措施，無法處理立即的出血風險。

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