— 降低風險 · MEDIUM · MCQ —
病人正在接受輸血，突然出現畏寒、發燒及下背痛。護理師應優先採取哪項措施？
A client is receiving a blood transfusion and begins to experience chills, fever, and low back pain. Which action should the nurse take first?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BSlow the transfusion rate減慢輸血速率
- CAdminister an antipyretic給予退燒藥
- DNotify the healthcare provider通知醫療提供者
— Explanation · 中文詳解 —
輸血反應中畏寒、發燒及下背痛是急性溶血反應（Acute Hemolytic Reaction）的特徵。護理師的第一反應必須是立刻停止輸血，並以生理食鹽水維持靜脈通路，以保護剩餘血袋與管路供後續實驗室分析，並防範過敏性休克。
Among transfusion reactions, chills, fever, and low back pain are characteristic of an acute hemolytic reaction. The nurse's first response must be to immediately stop the transfusion and maintain IV access with normal saline, in order to preserve the remaining blood unit and tubing for laboratory analysis and to guard against anaphylactic shock.
✦ 台美臨床差異
美國醫院有標準輸血反應 Protocol，護理師可直接依流程終止輸血；台灣多數仍需醫師醫囑才能停止，但在緊急狀況下護理師應先暫停再回報。