— 藥理與非經腸給藥 · HARD · MCQ —
病人疑似發生肝素誘發之血小板減少症（HIT），護理師應採取何種最適切的行動？
A client is diagnosed with suspected heparin-induced thrombocytopenia (HIT). Which nursing action is most appropriate?
- AAdminister a vitamin K bolus給予維生素K靜脈推注
- BApply pressure dressings to all puncture sites在所有穿刺部位施加加壓敷料
- CIncrease the heparin infusion rate增加肝素輸注速率
- DStop the heparin infusion immediately✓ 正解立即停止肝素輸注
— Explanation · 中文詳解 —
HIT 是由抗體介導的免疫反應，會導致血小板驟降並引發血栓風險。一旦懷疑 HIT，第一原則是立即停止所有肝素給藥（包含肝素鎖）。維生素 K 是華法林（Warfarin）的解毒劑，對肝素無效。加壓包紮無法解決凝血機能失調。
Heparin-induced thrombocytopenia (HIT) is an immune-mediated reaction that causes platelet destruction and a hypercoagulable state. The priority nursing action upon suspicion of HIT is to immediately stop all heparin infusions to halt the immune response. Continuing heparin or administering vitamin K, which reverses warfarin rather than heparin, would be ineffective or harmful.
✦ 台美臨床差異
HIT 的診斷與處置在兩地皆屬高警訊事件，台灣護理師通常會直接執行停藥並通報。