護理師正在檢視一位因肺栓塞接受持續靜脈注射肝素（Heparin）治療病人的實驗室報告。病人的 aPTT 為 110 秒。護理師應優先採取哪項措施？
The nurse is reviewing the laboratory results of a client receiving a continuous intravenous heparin infusion for a pulmonary embolism. The client’s aPTT is 110 seconds. Which action should the nurse take first?
- ADecrease the infusion rate according to the protocol依協議調低輸注速率
- BAssess the client for signs of bleeding評估病人是否有出血徵象
- CNotify the healthcare provider immediately立即通知醫療提供者
- DStop the heparin infusion✓ 正解停止肝素輸注
肝素治療的治療目標 aPTT 通常為對照值的 1.5 到 2.5 倍（約 46-70 秒）。當 aPTT 達到 110 秒時，病人面臨極高的自發性出血風險。根據安全照護原則，首要動作是「停止傷害源」，即立即停掉肝素輸注（Stop the infusion），這能最快中斷藥物對凝血機轉的過度抑制。雖然評估出血（B）和通知醫師（C）都是後續必要動作，但在高危急檢驗值（Critical Value）出現時，先執行安全保護措施（停止輸液）是防止併發症惡化的關鍵。調整劑量（A）通常用於 aPTT 輕微超出範圍時，110 秒已屬於嚴重過量，需先停藥再由醫師決定後續流量。
The therapeutic target aPTT for heparin therapy is generally 1.5 to 2.5 times the control value (approximately 46-70 seconds). When the aPTT reaches 110 seconds, the client is at very high risk of spontaneous bleeding. According to the principle of safe care, the first action is to "stop the source of harm," that is, immediately stop the heparin infusion, which most rapidly interrupts the drug's excessive suppression of coagulation. Assessing for bleeding (B) and notifying the provider (C) are both necessary follow-up actions, but when a critical laboratory value is present, performing the safety-protective action (stopping the infusion) first is essential to prevent worsening complications. Adjusting the dose (A) is generally used when the aPTT is only slightly out of range; 110 seconds already represents serious over-anticoagulation, so the drug must be stopped first and the subsequent infusion rate determined by the provider.
美國 NCLEX 考題邏輯中，面對危及生命的藥物濃度或數值，首選常是「停藥」；台灣臨床習慣上，護理師多會先「減速」並同步致電醫師確認是否要「停藥」，較少在無明確醫囑下直接關閉幫浦，除非有預設的 Heparin Protocol。