— 降低風險 · HARD · MCQ —
護理師正在為病人進行輸血，病人出現畏寒、側腹痛與發燒。護理師首要行動是什麼？
A nurse is caring for a client who is receiving a blood transfusion. The client develops chills, flank pain, and fever. What is the nurse's priority action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BSlow the transfusion rate減慢輸血速率
- CObtain vital signs測量生命徵象
- DNotify the physician通知醫師
— Explanation · 中文詳解 —
輸血過程中出現畏寒、側腹痛及發燒是急性溶血反應（Acute Hemolytic Reaction）的典型症狀。此時必須立即停止輸血以阻止更多破壞紅血球的抗體進入，並更換輸血管路（以生理食鹽水維持管路暢通），保護腎臟功能。
Chills, flank pain, and fever during transfusion are typical symptoms of an acute hemolytic reaction. The transfusion must be stopped immediately to prevent additional red-cell-destroying antibodies from entering, and the transfusion tubing must be changed (with normal saline used to maintain line patency) to protect renal function.
✦ 台美臨床差異
美台護理臨床指引在輸血反應處理上高度一致，均要求「立即停止」為第一優先動作。