— 藥理與非經腸給藥 · HARD · MCQ —
一位因深層靜脈血栓而接受肝素（Heparin）輸注的病人，護理師發現 aPTT 為 120 秒。優先採取何項措施？
A client is receiving heparin infusion for deep vein thrombosis. The nurse observes an aPTT of 120 seconds. What is the nurse's priority action?
- AStop the heparin infusion✓ 正解停止肝素輸注
- BIncrease the heparin infusion rate增加肝素輸注速率
- CObtain another blood sample to confirm the result抽取另一份血液樣本以確認結果
- DAdminister protamine sulfate給予硫酸魚精蛋白
— Explanation · 中文詳解 —
肝素的正常治療範圍通常為對照值的 1.5-2 倍。當 aPTT 高達 120 秒，代表抗凝血效果過強，出血風險極高。護理師應立即停止輸注，這是阻斷藥物進入體內的第一步。隨後應重新評估病人有無出血徵象並聯繫醫師，評估是否需要使用解毒劑。
An aPTT of 120 seconds indicates excessive anticoagulation and a high risk of bleeding, as therapeutic levels are typically 1.5 to 2 times the control value. The nurse's priority action is to stop the heparin infusion immediately to prevent further escalation of the bleeding risk. Subsequent steps include assessing for signs of bleeding and contacting the provider.
✦ 台美臨床差異
美台臨床皆採行抗凝血劑計量表（Nomogram），護理師需依據數據判斷並執行調整或停藥。