病人因肺栓塞接受持續肝素 (heparin) 輸注。護理師發現 aPTT 為 110 秒（對照值：30-40 秒）。護理師的首要行動為何？
A client is receiving a continuous infusion of heparin for a pulmonary embolism. The nurse notes the client's aPTT is 110 seconds (Control: 30-40 seconds). What is the nurse's priority action?
- AStop the infusion and notify the provider✓ 正解停止輸注並通知醫師
- BIncrease the infusion rate as per protocol依協議增加輸注速率
- CContinue the infusion at the current rate以目前速率繼續輸注
- DAdminister Vitamin K intramuscularly肌肉注射維生素 K
肝素 (heparin) 是一種常用的抗凝血劑，用於治療和預防血栓栓塞性疾病，如肺栓塞。肝素的劑量必須精確調整，以達到治療效果同時避免出血併發症。活化部分凝血酶原時間 (activated Partial Thromboplastin Time, aPTT) 是監測肝素治療效果的重要指標。 治療性 aPTT 的目標範圍通常是正常對照值的 1.5 到 2.5 倍。若對照值為 30-40 秒，則治療範圍約為 45-100 秒。病人目前的 aPTT 為 110 秒，已顯著超出治療範圍，表示抗凝血作用過強，出血風險極高。在這種情況下，護理師的首要行動是立即停止肝素輸注，以防止進一步的抗凝血作用，並立即通知醫師。這是根據「安全」和「降低風險潛能」的原則，優先處理可能危及生命的出血風險。 其他選項的行動會延誤處理或不適用於此情況。
Heparin is a commonly used anticoagulant for the treatment and prevention of thromboembolic disorders such as pulmonary embolism. The dose must be precisely titrated to achieve therapeutic effect while avoiding bleeding complications. The activated partial thromboplastin time (aPTT) is the key laboratory test used to monitor heparin therapy. The therapeutic aPTT target is typically 1.5 to 2.5 times the normal control value. With a control of 30-40 seconds, the therapeutic range is approximately 45-100 seconds. This client's aPTT of 110 seconds is significantly above the therapeutic range, indicating excessive anticoagulation and a very high bleeding risk. In this situation, the nurse's priority action is to immediately stop the heparin infusion to prevent further anticoagulation and notify the provider. This follows the principles of safety and reduction of risk potential by addressing a potentially life-threatening bleeding risk first. The other options either delay management or are inappropriate.