— 降低風險 · HARD · MCQ —
一位診斷為肺栓塞的病人開始接受靜脈血栓溶解劑（Alteplase, tPA）治療。下列哪項評估發現代表發生了嚴重併發症？
A client is diagnosed with a pulmonary embolism and started on intravenous Alteplase (tPA). Which assessment finding would indicate a major complication?
- ATemperature of 37.8°C (100°F)體溫 37.8°C (100°F)
- BSudden change in level of consciousness✓ 正解意識狀態突然改變
- CHeart rate of 98 beats/min心率 98 次/分
- DOozing from the peripheral IV site周邊靜脈注射部位滲血
— Explanation · 中文詳解 —
血栓溶解劑最危險的併發症是顱內出血（ICH）。意識狀態突然改變（如嗜睡、混亂、癲癇）可能是出血的首發跡象，需立即停藥並進行腦部 CT。靜脈穿刺點滲血（D）是常見副作用，雖需處理但不若 ICH 緊急。發燒和心率 98 均非 tPA 治療特異性的危急指標。
A sudden change in the level of consciousness is a critical indicator of intracranial hemorrhage, the most serious complication of alteplase therapy. While minor oozing at IV sites is common with fibrinolytic agents, neurological changes require immediate intervention. Slight fever and a heart rate of 98 beats/min are not specific signs of tPA toxicity or bleeding complications.
✦ 台美臨床差異
美國護理師在給予 tPA 時需嚴格執行神經學評估（如 NIHSS）；台灣在急重症單位亦有類似嚴格監測規範。