護理師照護一位因深部靜脈血栓接受持續型肝素（Heparin）輸注的病人。病人的 aPTT 為 120 秒（對照值：30-40 秒）。護理師應首先採取哪項行動？
A nurse is caring for a client receiving a continuous heparin infusion for deep vein thrombosis. The client's aPTT is 120 seconds (Control: 30-40 seconds). Which action should the nurse take first?
- ADraw a repeat blood sample for aPTT抽取重複血液樣本進行 aPTT 檢測
- BIncrease the heparin infusion rate增加肝素輸注速率
- CPrepare to administer vitamin K準備給予維生素 K
- DStop the heparin infusion✓ 正解停止肝素輸注
Heparin 的治療目標通常是將 aPTT 維持在對照值的 1.5 到 2.5 倍（即約 60-80 秒）。本題中病人的 aPTT 高達 120 秒，遠超過治療範圍，存在極高的出血風險。根據安全用藥原則，當檢驗值顯示藥物過量且具有潛在致命風險時，首要行動是「停止危害來源」，即立即停止（或依 protocol 暫停）肝素輸注。B 選項會加劇出血風險；C 選項維生素 K 是 Warfarin 的解毒劑，不是 Heparin 的（Heparin 應使用 Protamine sulfate）；A 選項重新抽血會延誤處理時機，在數值如此極端的情況下應先停藥再確認。護理師必須展現出對「出血安全」的即時判斷力，先停藥、再評估、最後回報與處理。
The therapeutic goal for heparin is generally to maintain the aPTT at 1.5 to 2.5 times the control value (approximately 60–80 seconds). In this scenario the client's aPTT is 120 seconds, far beyond the therapeutic range, with a very high risk of bleeding. Based on medication-safety principles, when a laboratory value indicates drug excess with a potentially lethal risk, the first action is to "stop the source of harm"—that is, immediately stop (or, per protocol, hold) the heparin infusion. Option B would worsen the bleeding risk; option C (vitamin K) is the antidote for warfarin, not for heparin (heparin reversal uses protamine sulfate); option A (redrawing labs) would delay management, and at such an extreme value the drug should be stopped before reconfirming. The nurse must demonstrate immediate judgment regarding "bleeding safety": stop the medication first, then assess, and finally report and address the situation.
美國醫院普遍採用標準化的「Heparin Protocol」，護理師可根據 aPTT 數值自主決定停藥或調整流速，不需每次詢問醫師。台灣則多數仍維持「看到報告 -> 回報醫師 -> 醫囑停藥」的流程，但 NCLEX 考的是護理師的自主臨床判斷，首選動作仍是停止危害。