— 降低風險 · MEDIUM · MCQ —
病人接受輸血過程中出現畏寒、發燒及下背痛。護理師首要採取什麼行動？
A client is receiving a blood transfusion and develops chills, fever, and low back pain. What is the nurse's priority action?
- AAdminister an antipyretic as prescribed依處方給予退燒藥
- BStop the transfusion immediately✓ 正解立即停止輸血
- CObtain a urine sample採集尿液樣本
- DSlow the rate of the transfusion減慢輸血速度
— Explanation · 中文詳解 —
輸血反應（Transfusion Reaction）中的急性溶血反應（Acute Hemolytic Reaction）表現為畏寒、發燒、下背痛、心跳過速、低血壓。這是嚴重的緊急狀況。護理師首要行動為「立刻停止輸血」，並更換輸液管路以生理食鹽水維持靜脈暢通，避免殘餘受污染血液繼續進入體內，隨後立即通報醫師。
An acute hemolytic transfusion reaction presents with chills, fever, low back pain, tachycardia, and hypotension. This is a serious emergency. The nurse's first action is to immediately stop the transfusion and replace the tubing with normal saline to maintain venous access, preventing any remaining contaminated blood from entering the body, and then notify the physician.