病人正在靜脈輸注肝素，護理師發現 PTT 值為對照值的 3 倍。護理師應優先採取哪項行動？
A client is receiving an intravenous infusion of heparin. The nurse notes a PTT result that is 3 times the control value. What is the priority nursing action?
- APrepare for a blood transfusion準備輸血
- BAdminister protamine sulfate給魚精蛋白
- CStop the infusion and notify the provider✓ 正解停止輸注並通知醫師
- DContinue the infusion as ordered依指示繼續輸注
肝素（Heparin）是一種抗凝血劑，治療目標通常是將 PTT 值維持在對照值的 1.5 到 2.5 倍之間。當 PTT 達到對照值的 3 倍時，代表抗凝血效果過強，病人處於極高的出血風險中。護理師的首要行動是立即停止輸注（Safety/Priority），以防藥物繼續進入體內，並立即通知醫師進行評估與採取必要處置。
A partial thromboplastin time (PTT) three times the control value indicates excessive anticoagulation and a high risk of hemorrhage, making it a medical emergency. The priority nursing action is to stop the heparin infusion immediately to prevent further anticoagulation and notify the healthcare provider. Protamine sulfate is reserved for cases with active, uncontrolled bleeding, and continuing the infusion would increase the risk of life-threatening complications.
在美國臨床，此類危急值（Critical value）通常會由實驗室直接通知，護理師需立即停止點滴並根據醫院 Protocol 進行回報，與台灣臨床流程大同小異。