— 藥理與非經腸給藥 · MEDIUM · MCQ —
肺栓塞病人被處方肝素(Heparin)靜脈衝擊劑量(Bolus)後接續持續滴注。護理師在開始滴注前應採取哪項行動?
A client with a pulmonary embolism is prescribed a heparin bolus followed by a continuous infusion. Which action should the nurse take before starting the infusion?
- AObtain baseline weight and aPTT取得基準體重和活化部分凝血活酶時間(aPTT)。
- BAssess the client's pupillary response評估病人的瞳孔反應。
- CAdminister Vitamin K as a prophylactic measure作為預防措施給予維生素K。
- DVerify the dose with a second licensed nurse✓ 正解與第二位持照護理師核對劑量。
— Explanation · 中文詳解 —
Heparin 屬於高風險藥物(High-alert medication)。在給藥前,必須由第二位執業護理師核對劑量(Double-check),以預防醫療錯誤。此外,雖然獲取基準體重與 aPTT 也很重要,但「安全核對」是預防嚴重給藥錯誤的核心護理標準。
Heparin is a high-alert medication. Before administration, a second licensed nurse must double-check the dose to prevent medication errors. In addition, although obtaining a baseline weight and aPTT is also important, safety verification is the core nursing standard for preventing serious medication errors.
✦ 台美臨床差異
美國與台灣皆有 High-alert medication 的雙人核對規範,但在美國 NCLEX 考試中,這是考查「安全與感染控制」的核心點。