— 生理適應 · EASY · MCQ —
一位病人正在接受輸血，出現輸血反應。何項為優先護理措施？
A client is receiving a blood transfusion and develops a transfusion reaction. Which is the priority nursing action?
- ANotify the healthcare provider通知醫療提供者
- BStop the transfusion immediately✓ 正解立即停止輸血
- CObtain a urine sample取得尿液樣本
- DAdminister an antihistamine給予抗組織胺
— Explanation · 中文詳解 —
輸血反應（Transfusion reaction）若發生，首要行動必須是「立即停止輸血（Stop the transfusion）」。這能阻斷過敏原或致病因子繼續進入病人體內。停止後，必須維持靜脈通路（使用生理食鹽水保持通暢），監測生命徵象，並通知醫師。保留血袋與輸血套組以供醫院檢驗，也是後續的重要步驟。
When a transfusion reaction occurs, the first action must be to immediately stop the transfusion. This prevents further entry of allergens or pathogens into the client. After stopping the transfusion, the nurse must maintain IV access (with normal saline kept patent), monitor vital signs, and notify the provider. Retaining the blood bag and tubing for hospital testing is also an important subsequent step.