— 照護管理 · HARD · SATA —
護理師照護一位持續靜脈輸注肝素（heparin）的病人，哪些發現應立即回報醫師？（選所有適合的）
The nurse is managing a client with a continuous IV infusion of heparin. Which findings should the nurse report to the provider immediately? (Select all that apply.)
- APresence of dark, tarry stools✓ 正解出現黑色焦油樣糞便
- BAPTT level of 1.5 times the controlAPTT 值為對照組的 1.5 倍
- CSmall area of bruising at the IV site靜脈注射處有小面積瘀青
- DClient reports severe, sudden headache✓ 正解病人主訴嚴重且突發的頭痛
- EBleeding from the gums during brushing✓ 正解刷牙時牙齦出血
— Explanation · 中文詳解 —
肝素治療期間需嚴密監測出血徵兆。黑色瀝青便（腸胃道出血）、突發劇烈頭痛（顱內出血高風險）及牙齦出血均顯示藥物反應過強或存在出血點。APTT 1.5 倍屬於治療區間內，瘀青則為常見副作用，需紀錄但不必立即回報。
The nurse must immediately report signs of serious bleeding, such as melena indicating gastrointestinal hemorrhage, sudden severe headaches suggesting intracranial bleeding, and gingival bleeding reflecting excessive systemic anticoagulation. While minor bruising and an aPTT of 1.5 times control are expected or within therapeutic ranges, these critical findings require urgent provider intervention.
✦ 台美臨床差異
美國護理師常依 Nomogram 調整劑量，台灣則多由醫師依報告數值調整醫囑。