— 照護管理 · MEDIUM · MCQ —
護理師照顧一位使用肝素（Heparin）持續靜脈輸注的病人，哪項實驗室數值需要立即處理？
A nurse is caring for a client with a continuous heparin infusion. Which laboratory value requires immediate action?
- AHematocrit 38%血球容積 38%
- BINR 1.2國際標準化比值 1.2
- CPlatelet count 150,000/mm³血小板計數 150,000/mm³
- DaPTT 120 seconds✓ 正解活化部分凝血活酶時間 120 秒
— Explanation · 中文詳解 —
肝素（Heparin）持續輸注需要嚴格監測部分凝血活酶時間（aPTT），以確保抗凝血效果在治療範圍內（通常為正常值的 1.5-2.5 倍）。當 aPTT 高達 120 秒時，表示凝血能力嚴重受抑制，出血風險極大。護理師應立即暫停給藥，並通知醫師評估是否需要拮抗劑（如魚精蛋白，Protamine sulfate）。
Continuous heparin infusion requires strict monitoring of activated partial thromboplastin time (aPTT) to ensure anticoagulation remains within the therapeutic range (usually 1.5 to 2.5 times the normal value). An aPTT of 120 seconds indicates that coagulation is severely suppressed and the risk of bleeding is extremely high. The nurse should immediately stop the infusion and notify the provider to determine whether an antidote (such as protamine sulfate) is needed.