— 降低風險 · HARD · MCQ —
護理師照顧一位正進行輸血的病人。輸血開始 15 分鐘後，病人表示背痛且畏寒。護理師的第一步行動為何？
A nurse is caring for a client who is receiving blood transfusion therapy. The client reports back pain and chills 15 minutes after the transfusion begins. What is the nurse's first action?
- AObtain vital signs測量生命徵象
- BNotify the health care provider通知醫療提供者
- CInfuse 0.9% normal saline輸注 0.9% 生理食鹽水
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
輸血反應（Transfusion reaction）的處理原則是：立即停止輸血（Stop transfusion）、維持靜脈通路（Keep vein open with saline）、通知醫師（Notify provider）、監測生命徵象（Monitor VS）。出現背痛與畏寒是急性溶血反應（Acute Hemolytic Reaction）的警訊，必須立即動作。
The management of a transfusion reaction follows these principles: stop the transfusion immediately, keep the vein open with normal saline, notify the provider, and monitor vital signs. Back pain and chills are warning signs of an acute hemolytic reaction and require immediate action.
✦ 台美臨床差異
美國醫院有極其嚴格的輸血程序，輸血反應發生時，必須立即將血袋與管路送回血庫（Blood bank）進行分析，護理師需熟悉此送檢流程。