— 降低風險 · HARD · MCQ —
病人正在接受輸血，突然出現呼吸困難、胸痛與低血壓。護理師應優先採取哪項措施？
A client is receiving a blood transfusion and begins to exhibit dyspnea, chest pain, and hypotension. Which action should the nurse take first?
- ANotify the healthcare provider通知醫療提供者
- BStop the transfusion immediately✓ 正解立即停止輸血
- CSlow the rate of the transfusion減緩輸血速度
- DAdminister diphenhydramine給予苯海拉明
— Explanation · 中文詳解 —
輸血反應中出現生命徵象改變（低血壓、呼吸困難）代表發生嚴重急性溶血或過敏反應。此時的首要原則為切斷過敏原輸入，即立即停止輸血。保留靜脈通路並以生理食鹽水維持管路通暢，接著才是通知醫師與執行後續搶救處置，不可減速而應徹底停止。
A change in vital signs (hypotension, dyspnea) during a transfusion reaction indicates a severe acute hemolytic or anaphylactic reaction. The first principle is to cut off the input of the allergen, which means immediately stopping the transfusion. Maintain IV access and keep the line patent with normal saline, then notify the physician and carry out subsequent rescue measures; never simply slow the rate, but completely stop it.
✦ 台美臨床差異
美台臨床對於輸血反應流程一致，強調第一時間關閉輸血管路並確保靜脈路徑暢通。