— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人進行肝素治療，測得 aPTT 為 120 秒。護理師應採取何種優先措施？
A client receiving heparin therapy has an aPTT of 120 seconds. What is the nurse's priority action?
- AStop the heparin infusion immediately✓ 正解立即停止肝素輸注
- BAssess the client for signs of internal bleeding評估病人是否有內部出血徵象
- CPrepare to administer vitamin K準備給予維生素 K
- DAdminister the next dose of heparin as scheduled按預定時間給予下一劑肝素
— Explanation · 中文詳解 —
肝素治療的目標 aPTT 通常為正常值的 1.5 到 2.5 倍。120 秒遠高於預期範圍，顯示出血風險極高。首要動作應為立即停藥，避免出血加劇，隨後通知醫師並評估病人狀態。維生素 K 是華法林（Warfarin）的拮抗劑，並非肝素的解毒劑。
An aPTT of 120 seconds is significantly above the therapeutic range, indicating a high risk for hemorrhage. The nurse must immediately stop the heparin infusion to prevent further anticoagulation before notifying the provider or assessing for bleeding. Vitamin K is the antidote for warfarin, not heparin.
✦ 台美臨床差異
台美臨床皆依據醫院設定之 nomogram 調整肝素滴速；此類高警訊藥物在兩地均需嚴格遵守護理師雙人核對。