— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正照護一位接受靜脈注射肝素（heparin）的病人。病人的 PTT 為 85 秒。肝素的治療 PTT 範圍為對照值的 1.5 至 2 倍。對照組 PTT 為 30 秒。最恰當的護理措施為何？
A nurse is caring for a client receiving intravenous heparin. The client's PTT is 85 seconds. The therapeutic PTT range is 1.5 to 2 times the control. The control PTT is 30 seconds. What is the most appropriate nursing action?
- ADecrease the rate of the heparin infusion by 2 mL/hr.將肝素輸注速率減慢 2 mL/hr
- BAdminister the prescribed heparin infusion.給予處方的肝素輸注
- CHold the heparin infusion for 1 hour and notify the physician.✓ 正解暫停肝素輸注 1 小時並通知醫師
- DIncrease the rate of the heparin infusion by 2 mL/hr.將肝素輸注速率加快 2 mL/hr
— Explanation · 中文詳解 —
肝素（Heparin）治療需要嚴格監測 PTT 值，以維持抗凝血效果在治療窗內。治療窗通常為對照值的 1.5 到 2 倍。此病人的目標值為 45-60 秒（30x1.5 至 30x2）。病人目前的 PTT 為 85 秒，顯示抗凝血效果過強，有引發致命性出血的風險。此時應立即暫停給藥並通知醫師，這是護理師依據 protocol 的安全處置。
The therapeutic PTT range for heparin is 1.5 to 2 times the control value, resulting in a target of 45 to 60 seconds for this client. Since the current PTT of 85 seconds indicates excessive anticoagulation and increased bleeding risk, the nurse should hold the infusion and notify the physician immediately.