— 降低風險 · HARD · MCQ —
護理師正為病人進行輸血，病人出現畏寒、側腹痛與心跳過速。護理師的優先措施為何？
A nurse is caring for a client who is receiving a blood transfusion. The client develops chills, flank pain, and tachycardia. What is the nurse's priority action?
- ANotify the physician immediately立即通知醫師
- BSlow the transfusion rate減慢輸血速率
- CFlush the IV line with normal saline以生理食鹽水沖洗靜脈通路
- DStop the transfusion and disconnect the tubing✓ 正解停止輸血並斷開輸血管路
— Explanation · 中文詳解 —
病人出現畏寒、側腹痛與心跳過速，高度懷疑發生急性溶血性輸血反應（Acute Hemolytic Reaction）。這是危及生命的緊急狀況。首要步驟是立即停止輸血，並更換新輸液管路使用生理食鹽水維持管路通暢，避免持續輸入殘留在管路中的血液導致嚴重後果。
The client's chills, flank pain, and tachycardia strongly suggest an acute hemolytic transfusion reaction, a life-threatening emergency. The first step is to immediately stop the transfusion and disconnect the existing tubing, then maintain venous access with new tubing and normal saline to avoid further infusion of any blood remaining in the line, which could lead to severe consequences.
✦ 台美臨床差異
兩地標準程序均要求立即停止輸血並以生理食鹽水維持管路通暢，差別在於美國多由護理師主動發起實驗室檢查（血液、尿液）。