— 降低風險 · HARD · MCQ —
一位接受輸血的病人,哪項評估發現需要護理師立即停止輸血?
Which assessment finding in a client receiving a blood transfusion requires the nurse to stop the infusion immediately?
- ASlightly elevated pulse rate脈搏率輕微升高
- BLow-grade fever (99.8°F / 37.7°C)低燒 (99.8°F / 37.7°C)
- CMild itching without rash輕微搔癢且無皮疹
- DFlank pain and hypotension✓ 正解腰部疼痛和低血壓
— Explanation · 中文詳解 —
腰痛(Flank pain)伴隨低血壓是急性溶血反應(Acute hemolytic reaction)的經典徵兆,這屬於輸血反應中最嚴重的緊急狀況,必須立即停止輸血並以生理食鹽水維持管路通暢。發燒與癢通常可進一步評估或由醫囑處理,但急性溶血直接危及生命。
Flank pain accompanied by hypotension is a classic sign of an acute hemolytic reaction, the most serious transfusion emergency. The transfusion must be stopped immediately and the IV line kept patent with normal saline. Fever and itching can often be evaluated further or managed per provider order, but acute hemolysis is immediately life-threatening.
✦ 台美臨床差異
美國護理師依 protocol 執行輸血處置,台灣多由護理師監測並需醫師簽章確認,流程極為嚴謹。