病人正在進行肝素持續靜脈輸注，護理師發現活化部分凝血活酶時間 (aPTT) 為 120 秒。護理師的首要行動為何？
A client is receiving a continuous intravenous infusion of heparin. The nurse notes an activated partial thromboplastin time (aPTT) of 120 seconds. What is the nurse's priority action?
- AContinue the infusion at the current rate以目前速率繼續輸注
- BStop the heparin infusion✓ 正解停止肝素輸注
- CPrepare to administer protamine sulfate準備施用硫酸魚精蛋白
- DIncrease the heparin dosage增加肝素劑量
正常的 aPTT 控制範圍通常為對照值的 1.5-2.5 倍。120 秒遠高於一般治療範圍（通常 60-80 秒），顯示出血風險極高。護理師應立即暫停藥物輸注，避免進一步延長凝血時間，隨後通知醫師評估是否需要解毒劑或調整劑量。C 選項雖然是正確的解毒劑，但必須在醫師評估出血嚴重度後才給予，不可直接準備給予。
The therapeutic aPTT range for heparin is typically 1.5–2.5 times the control value. An aPTT of 120 seconds is well above the usual therapeutic range (typically 60–80 seconds), indicating a very high risk of bleeding. The nurse should immediately stop the infusion to prevent further prolongation of clotting time and then notify the physician for evaluation of the need for an antidote or dose adjustment. Although option C (protamine sulfate) is the correct antidote, it should be given only after physician evaluation of bleeding severity, not prepared and administered independently by the nurse.
美國護理師常有依據 Nomogram 調整劑量的授權；台灣通常需醫師親自確認數值並開立醫囑後方可調整或停藥。