— 藥理與非經腸給藥 · HARD · MCQ —
病人正接受肝素（Heparin）持續點滴。PTT 結果為 120 秒。優先的護理處置為何？
A client is receiving a continuous heparin infusion. The PTT is 120 seconds. What is the priority nursing action?
- AIncrease the IV rate增加靜脈點滴速率
- BContinue infusion and recheck in 6 hours繼續輸注並於 6 小時後複測
- CAdminister protamine sulfate給藥硫酸魚精蛋白
- DStop the infusion and notify the provider✓ 正解停止輸注並通知醫師
— Explanation · 中文詳解 —
肝素（Heparin）治療的治療範圍（Therapeutic range）通常為 PTT 對照值的 1.5 至 2.5 倍。當 PTT 達到 120 秒時，已遠超過安全範圍，病人面臨極高的出血風險（如內出血、顱內出血）。護理師的優先行動應是終止藥物輸注以移除致病源，並立即通知醫師進行評估與調整，而非繼續觀察或自行調整劑量。
A PTT of 120 seconds indicates excessive anticoagulation, placing the client at high risk for serious bleeding complications. The priority nursing action is to stop the heparin infusion immediately to prevent further anticoagulation and notify the healthcare provider for evaluation and potential reversal.