— 降低風險 · HARD · MCQ —
護理師監測接受輸血的病人時，病人出現寒顫、腰痛與發燒。首要護理措施為何？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, flank pain, and fever. What is the priority nursing action?
- AAdminister the prescribed acetaminophen給予處方之乙醯胺酚
- BStop the blood transfusion immediately✓ 正解立即停止輸血
- CSlow the rate of infusion減慢輸注速率
- DObtain an emergency vital sign check進行緊急生命徵象測量
— Explanation · 中文詳解 —
病徵（腰痛、寒顫、發燒）顯示可能發生急性溶血反應，這是致命性的緊急事件。首要動作是立即停止輸血，拔除輸血管路並以生理食鹽水維持管路通暢，接著通知醫師並保留血袋進行後續檢驗。任何其他處置皆不可延誤停輸血的動作。
These signs (flank pain, chills, fever) suggest an acute hemolytic transfusion reaction, a potentially fatal emergency. The priority action is to immediately stop the transfusion, disconnect the transfusion tubing, and maintain IV patency with normal saline; then notify the physician and save the blood bag for subsequent testing. No other action may delay stopping the transfusion.
✦ 台美臨床差異
台美皆遵循相同緊急輸血反應程序，重點皆在於「先停輸血、後續處置」，台灣法規更強調血袋需送回血庫檢驗。