護理師發現一位接受持續肝素滴注的病患發生了急性鼻血，且血壓突然下降。目前的 aPTT 檢驗結果回報為 140 秒。首要護理行動為何？
An intensive care nurse discovers that a client with a continuous heparin infusion for a pulmonary embolism has experienced an acute nosebleed and has a sudden drop in blood pressure. The current aPTT result comes back at 140 seconds. What is the priority nursing action?
- AApply firm direct pressure to the client's nose.對病人鼻子施加緊密直接壓力
- BImmediately stop the heparin infusion and prepare protamine sulfate.✓ 正解立即停止肝素輸注並準備硫酸普魯卡因胺
- CBolus the client with 500 mL of normal saline.快速注射 500 mL 生理食鹽水
- DSlow the continuous heparin infusion rate by half.將持續肝素輸注速率減半
本題測驗危險藥物毒性管理。肝素治療的目標 aPTT 通常為 46-70 秒。aPTT 140 秒代表嚴重中毒，合併出血與休克。對於任何點滴毒性反應，第一步永遠是「立刻停止點滴」以切斷來源，並準備專屬解毒劑魚精蛋白(Protamine sulfate)。
This question tests management of dangerous medication toxicity. The target aPTT for heparin therapy is typically 46-70 seconds. An aPTT of 140 seconds represents severe toxicity combined with bleeding and shock. For any infusion toxicity reaction, the first step is always to immediately stop the infusion to cut off the source, and prepare the specific antidote, protamine sulfate.
任何藥物毒性首要步驟就是先關掉它(Stop it)，接著再通報或做其他處置。