— 生理適應 · MEDIUM · MCQ —
病人正在進行輸血，出現畏寒、側腹疼痛及發燒症狀。護理師優先採取之措施為何？
A client 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 rate of infusion調慢輸注速度
- CAdminister acetaminophen給予乙醯胺酚
- DNotify the laboratory通知檢驗室
— Explanation · 中文詳解 —
病人出現畏寒、側腹痛與發燒，高度懷疑為急性溶血性輸血反應。此反應係因捐贈者血液與受血者血液不相容，抗體攻擊紅血球導致溶血。第一優先動作永遠是停止輸血，確保不再有致敏原進入循環，隨後維持靜脈管路暢通以輸注生理食鹽水。
The client's chills, flank pain, and fever strongly suggest an acute hemolytic transfusion reaction. This reaction occurs because the donor blood is incompatible with the recipient's blood, and antibodies attack the red blood cells, causing hemolysis. The first priority is always to stop the transfusion to ensure that no further sensitizing agent enters the circulation, followed by maintaining IV access with normal saline.
✦ 台美臨床差異
台美臨床對於輸血反應的標準流程極為一致，皆要求立即停止輸血並更換生理食鹽水管路。