— 生理適應 · HARD · MCQ —
病人在輸血過程中出現腰痛、發燒與畏寒，護理師的首要行動是什麼？
A client is receiving a blood transfusion and develops flank pain, fever, and chills. What is the nurse's priority action?
- AStop the blood transfusion✓ 正解停止輸血
- BAdminister acetaminophen給予乙醯胺酚
- CSlow the infusion rate減慢輸注速率
- DNotify the laboratory通知檢驗科
— Explanation · 中文詳解 —
病人出現腰痛、發燒、畏寒，高度懷疑為急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）。這是輸血中最危險的併發症，通常因 ABO 血型不相容導致。護理師必須立刻停止輸血，確保病人安全，並依據機構規定保留血袋與管路以利實驗室分析，並維持靜脈管路通暢以供搶救藥物使用。
When a patient develops flank pain, fever, and chills during a transfusion, an acute hemolytic transfusion reaction must be strongly suspected. This is the most dangerous complication of transfusion and is usually due to ABO incompatibility. The nurse must immediately stop the transfusion to ensure patient safety, retain the blood bag and tubing per institutional policy for laboratory analysis, and maintain IV access for resuscitative medications.