— 降低風險 · HARD · MCQ —
護理師照護一位接受輸血治療的病人。若懷疑發生輸血反應，護理師優先採取的行動為何？
A nurse is providing care for a client who is receiving blood transfusion therapy. Which action is priority if the nurse suspects a transfusion reaction?
- AObtain vital signs測量生命徵象
- BNotify the healthcare provider通知醫療提供者
- CFlush the IV line with normal saline以生理食鹽水沖洗靜脈通路
- DStop the transfusion✓ 正解停止輸血
— Explanation · 中文詳解 —
輸血反應發生時，任何延遲都可能加劇溶血反應的嚴重度。優先順序為：立即停止輸血、維持管路通暢（更換管路以生理食鹽水緩慢滴注）、通知醫療團隊、收集輸血袋與數據進行檢驗。停止輸血是終止過敏原持續進入的關鍵。
When a transfusion reaction occurs, any delay can worsen the severity of hemolysis. The priority sequence is: immediately stop the transfusion, maintain a patent line (changing tubing and slowly infusing normal saline), notify the healthcare team, and collect the blood bag and laboratory data for analysis. Stopping the transfusion is the key step in halting continued exposure to the antigen.
✦ 台美臨床差異
美台輸血流程標準一致，均要求立即停止輸血並以生理食鹽水維持管路暢通，防範過敏原續進。