— 藥理與非經腸給藥 · HARD · MCQ —
一位接受肝素治療深層靜脈栓塞的病人，血小板計數從 250,000 降至 100,000/mm³。護理師的優先行動為何？
A client receiving heparin therapy for deep vein thrombosis (DVT) develops a platelet count drop from 250,000 to 100,000/mm³. What is the nurse's priority action?
- AAdminister protamine sulfate intravenously靜脈注射硫酸魚精蛋白
- BPrepare the client for a blood transfusion準備為病人輸血
- CDiscontinue the heparin infusion immediately✓ 正解立即停止肝素輸注
- DContinue the infusion and recheck the count in 4 hours繼續輸注並於 4 小時後重新檢查血小板計數
— Explanation · 中文詳解 —
血小板在短時間內下降超過 50% 或低於 100,000/mm³，是肝素引起之血小板低下症（Heparin-Induced Thrombocytopenia, HIT）的典型徵兆。HIT 是一種危及生命的免疫介導併發症，會導致全身性血栓形成。護理師的首要行動是立即停止肝素輸注，以阻斷免疫反應的持續刺激，並通知醫師更換為非肝素類的抗凝血劑（如 Argatroban）。
A platelet count drop exceeding 50% or falling below 100,000/mm³ suggests heparin-induced thrombocytopenia (HIT), a serious immune-mediated condition that increases thrombotic risk. The nurse's priority action is to immediately discontinue the heparin infusion to halt the immune response and notify the provider for alternative anticoagulation.