護理師照護靜脈滴注 Heparin 的病人，發現病人牙齦出血。首要措施為何？
A nurse is caring for a client with a continuous IV infusion of Heparin. The nurse notes the client's gums are bleeding. What is the priority action?
- ACheck the most recent aPTT result檢查最近的活化部分凝血活酶時間 (aPTT) 結果
- BNotify the healthcare provider通知醫療提供者
- CApply pressure to the bleeding area對出血部位施加壓力
- DStop the heparin infusion✓ 正解停止肝素靜脈滴注
當病人接受 Heparin（肝素）點滴治療時，護理師必須隨時警覺出血風險。牙齦出血是活動性出血的早期徵兆，暗示病人的凝血功能可能已被過度抑制。在 NCLEX 的優先順序原則（Priority Action）中，第一步通常是「停止造成傷害的原因（Stop the cause）」。繼續給藥會加劇出血風險，甚至導致內出血（如顱內出血或腸胃道出血）。停止點滴後，護理師應立即評估病人徵象、確認最新的 aPTT 數值，並通知醫師決定是否給予解毒劑 Protamine sulfate。這體現了「安全（Safety）」優先於「評估（Assessment）」的臨床急迫性邏輯。
When a client is receiving a continuous heparin infusion, the nurse must remain vigilant for bleeding. Gum bleeding is an early sign of active bleeding and suggests that the client's coagulation function may be excessively suppressed. According to NCLEX priority-action principles, the first step is usually to stop the cause of harm. Continuing the infusion will aggravate bleeding risk and may cause internal bleeding (such as intracranial or gastrointestinal hemorrhage). After stopping the infusion, the nurse should immediately assess the client, verify the most recent aPTT, and notify the provider to determine whether to administer the antidote protamine sulfate. This reflects the clinical principle that safety takes precedence over assessment in an urgent situation.
美國護理實務非常強調護理師的獨立判斷權（Autonomy），在發現明顯出血風險時，護理師有權且有責任先停止點滴。台灣臨床環境有時較強調先請示醫師，但在 NCLEX 考試中，必須選擇「先停藥」以符合安全原則。