— 降低風險 · MEDIUM · MCQ —
護理師監測一位正在輸血的病人，病人出現畏寒、發燒及下背痛。護理師應優先採取的措施為何？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, fever, and low back pain. What is the priority nursing action?
- ASlow the rate of the transfusion減慢輸血速率
- BStop the transfusion immediately✓ 正解立即停止輸血
- CNotify the laboratory通知檢驗科
- DAdminister acetaminophen給予乙醯胺酚
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute hemolytic transfusion reaction）是輸血中最危險的併發症，通常因 ABO 血型不合導致。症狀包括發燒、畏寒、低背痛、低血壓、心跳過速及血紅素尿。護理師一旦懷疑，必須立即採取行動：停止輸血、維持管路通暢（用生理食鹽水）、通知醫師、保存剩餘血品送回檢驗。
Acute hemolytic transfusion reaction is the most dangerous complication of transfusion and is typically caused by ABO incompatibility. Symptoms include fever, chills, low back pain, hypotension, tachycardia, and hemoglobinuria. Once suspected, the nurse must act immediately: stop the transfusion, maintain a patent IV line with normal saline, notify the physician, and preserve the remaining blood product for laboratory analysis.