— 降低風險 · HARD · MCQ —
護理師正在照顧一位接受輸血的病人。病人開始主訴脅腹痛、發冷與發熱。護理師應採取的第一優先措施是什麼？
A nurse is caring for a client who is receiving blood transfusion. The client begins to complain of flank pain, chills, and fever. What is the nurse's priority action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BObtain vital signs測量生命徵象
- CNotify the healthcare provider通知醫療提供者
- DSlow the rate of infusion減慢輸注速度
— Explanation · 中文詳解 —
這是典型的急性溶血性輸血反應，起因於 ABO 不相容。一旦發生，必須立即停止輸血以防止進一步的溶血。應保留輸血管路與剩餘血液以便檢驗，改以生理食鹽水維持靜脈路徑通暢，防止循環崩潰，並立即採取後續的監測與回報步驟。
This is a classic acute hemolytic transfusion reaction caused by ABO incompatibility. Once it occurs, the transfusion must be stopped immediately to prevent further hemolysis. The transfusion tubing and remaining blood must be retained for laboratory analysis, normal saline should be initiated to keep the IV line patent and prevent circulatory collapse, and subsequent monitoring and reporting steps must be carried out promptly.
✦ 台美臨床差異
美台針對輸血反應處理流程一致，均強調立即停止輸血、維持靜脈通路及通知醫療團隊。