加護病房護理師發現接受持續肝素滴注的病患出現急性大量腸胃道出血。目前的 aPTT 結果為 150 秒。護理師『立刻停止了肝素滴注』。接下來立刻的首要護理行動為何？
An intensive care nurse discovers that a client with a continuous heparin infusion has an acute massive gastrointestinal bleed. The current aPTT result is 150 seconds. The nurse instantly stops the heparin drip. What is the very next immediate priority nursing action?
- AUrgently instruct the UAP tightly to measure the client’s vital signs strictly.緊急指示未經認證的護理人員（UAP）嚴格測量病人的生命徵象
- BAdminister STAT intravenous Vitamin K deeply immediately securely boldly.立即深層靜脈注射維他命 K
- CApply firm direct pressure safely to the client's rigid stomach effectively entirely.對病人堅硬的腹部施加有力的直接壓力
- DNotify the physician immediately and prepare to administer protamine sulfate.✓ 正解立即通知醫師並準備施用硫酸魚精蛋白
本題測驗危險藥物毒性之解毒劑關聯 (Antidote/Toxicity Prioritization)。病患已經被「停止滴注肝素」了，接下來必須對抗肝素留在體內的毒性與正在進行的出血。通報醫師並準備『魚精蛋白 (Protamine sulfate)』是肝素過量唯一且絕對的黃金解毒劑。選項 B 錯誤，維他命 K (Vitamin K) 是口服藥 Warfarin (Coumadin) 的解毒劑，對肝素無效。選項 A 測量生命徵象是對的，但在出血量極大且已知是因為抗凝血劑中毒時，給解毒劑是救命根本（更何況這種不穩定狀態不能推給 UAP 去量）。
This question tests the association between dangerous drug toxicity and antidote (Antidote/Toxicity Prioritization). The client's heparin infusion has already been stopped, so the next step is to counteract the heparin toxicity remaining in the body and the ongoing bleeding. Notifying the physician and preparing to administer 'protamine sulfate' is the only and absolute gold-standard antidote for heparin overdose. Option B is incorrect: Vitamin K is the antidote for the oral medication warfarin (Coumadin) and has no effect on heparin. Option A (measuring vital signs) is correct, but when the bleeding is severe and known to be due to anticoagulant toxicity, administering the antidote is fundamental to saving life (moreover, this unstable status cannot be delegated to the UAP).
Heparin 解毒劑是 Protamine sulfate；Warfarin 解毒劑是 Vitamin K。此為送分對話題。