護理師照護一名持續靜脈輸注肝素（Heparin）的病人。下列哪些發現需要立即介入？（選所有適合的）
A nurse is caring for a client receiving continuous IV heparin. Which of the following findings would require immediate intervention? (Select all that apply.)
- ADark, tarry stools noted✓ 正解注意到黑糞
- BSudden onset of severe headache✓ 正解突然發作嚴重頭痛
- CPTT result of 45 seconds (Control 25-35s)活化部分凝血活酶時間 (PTT) 結果為 45 秒 (對照組 25-35 秒)
- DSmall ecchymosis at the IV insertion site靜脈注射部位有小面積瘀斑
- EGingival bleeding while brushing teeth✓ 正解刷牙時牙齦出血
肝素治療期間需監控異常出血。柏油樣便（腸胃道出血）、突發性頭痛（可能顱內出血）、牙齦出血皆屬危險徵象。C 為治療範圍內（通常為對照組 1.5-2.5 倍），屬預期效果；D 為注射點輕微瘀青，屬常見臨床觀察，非立即危急。
During heparin therapy, the nurse must monitor for abnormal bleeding. Tarry stools (gastrointestinal bleeding), sudden-onset headache (possible intracranial hemorrhage), and gingival bleeding are all dangerous findings. Option C is within the therapeutic range (usually 1.5-2.5 times the control value) and represents the expected effect; option D is mild ecchymosis at the IV site, a common clinical finding and not an immediate emergency.
美台對肝素監測值設定的標準倍數有時會隨醫院規範（Nomogram）略有差異，應以單位臨床指引為主。