— 藥理與非經腸給藥 · MEDIUM · SATA —
病人正在進行肝素持續輸注，護理師應監測下列哪些潛在副作用徵兆？（選所有適合的）
A nurse is caring for a client receiving a continuous infusion of heparin. Which signs should the nurse monitor for potential adverse effects? (Select all that apply.)
- AHematuria✓ 正解血尿
- BBruising at the injection site✓ 正解注射部位瘀青
- CBlack, tarry stools✓ 正解黑色焦油樣糞便
- DIncreased blood pressure血壓升高
- EEpistaxis✓ 正解鼻出血
— Explanation · 中文詳解 —
肝素為抗凝血劑，最常見的副作用為出血。護理師需進行全身性出血評估，包括血尿（腎功能與凝血異常指標）、瘀青（皮下微血管破裂）、黑便（上消化道出血徵兆）及鼻出血。血壓升高並非肝素的直接副作用，需排除其他血管病變。
Heparin is an anticoagulant that increases the risk of bleeding, so nurses must monitor for signs such as hematuria, epistaxis, bruising, and melena. These findings indicate potential internal or external bleeding complications, whereas increased blood pressure is not a direct adverse effect of heparin therapy.
✦ 台美臨床差異
台美皆重視出血預警系統；美國護理師常執行結構化的出血評估表（Bleeding Score），台灣則多依賴護理評估報告。