— 降低風險 · MEDIUM · MCQ —
病人正在接受輸血，突然出現畏寒、下背痛及心跳過速。護理師的優先處置為何？
A client is receiving a blood transfusion and begins to experience chills, low back pain, and tachycardia. What is the nurse's priority action?
- ANotify the laboratory of a clerical error通知實驗室有行政疏失
- BSlow the rate of infusion減緩輸注速率
- CAdminister an antihistamine per standing order依常規醫囑給予抗組織胺
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
輸血反應（Transfusion reaction）的症狀如畏寒、下背痛與心跳過速，是急性溶血性輸血反應（Acute hemolytic reaction）的典型表現。這是由於 ABO 血型不合引起的嚴重免疫反應。護理師首要行動是立即「停止輸血」，斷開輸血管路，以減少溶血因子進入體內，隨後維持靜脈通路並通知醫師。
Transfusion reaction symptoms such as chills, low back pain, and tachycardia are classic manifestations of an acute hemolytic transfusion reaction caused by ABO incompatibility. The nurse's priority is to immediately stop the transfusion and disconnect the tubing to reduce the entry of hemolytic factors into the body, then maintain IV access and notify the physician.