一位深部靜脈栓塞病人正在接受肝素（Heparin）滴注。護理師注意到實驗室數值：aPTT 為 90 秒（對照值：25-35 秒）。護理師應優先採取哪項行動？
A client with deep vein thrombosis is receiving a heparin infusion. The nurse notes the following laboratory results: aPTT 90 seconds (control: 25-35 seconds). Which action should the nurse take first?
- ARecheck the aPTT in 2 hours.2 小時後重新檢測 aPTT
- BNotify the healthcare provider immediately.立即通知醫療提供者
- CStop the heparin infusion for 1 hour and restart at a lower rate.✓ 正解停止肝素滴注 1 小時，並以較低速率重新開始
- DAdminister protamine sulfate as prescribed.依醫囑給予硫酸魚精蛋白
肝素（Heparin）滴注的治療目標通常是使 aPTT 維持在正常對照值的 1.5 到 2.5 倍之間。以此題對照值 25-35 秒計算，治療區間約為 46-88 秒。病人的 aPTT 為 90 秒，已超過治療範圍上限，存在出血風險。根據臨床肝素滴注協議（Heparin Protocol），首要動作通常是暫停輸注（Hold）一段時間（如 1 小時），然後依據醫囑調低劑量重新開始。通知醫師（B）雖然必要，但在暫停藥物後進行才符合優先處理風險的原則。Protamine sulfate（D）是拮抗劑，通常僅在發生明顯活動性大出血或 aPTT 極度延長時使用，90 秒尚不需立即使用拮抗劑。此題考驗護理師對滴注協議的執行力與優先順序判斷。
The therapeutic goal of a heparin infusion is generally to maintain the aPTT at 1.5 to 2.5 times the normal control value. Using this question's control range of 25-35 seconds, the therapeutic window is approximately 46-88 seconds. The client's aPTT of 90 seconds is above the upper limit of the therapeutic range, posing a bleeding risk. According to standard clinical heparin protocols, the priority action is generally to hold the infusion for a period (such as 1 hour) and then restart at a reduced rate per the order. Notifying the provider (B) is necessary but is performed after stopping the medication, consistent with the principle of acting to mitigate risk first. Protamine sulfate (D) is the antidote and is reserved for overt active major bleeding or extremely prolonged aPTT; an aPTT of 90 seconds does not yet require its immediate use. This question tests the nurse's ability to follow infusion protocols and prioritize correctly.
美國醫院普遍採用電子化的 Heparin Protocol 系統，護理師具有較高的自主權根據實驗室結果直接調整滴注速度；台灣則多數仍需先電話詢問醫師，由醫師在電腦下達調整醫囑後護理師才執行。