— 降低風險 · HARD · MCQ —
護理師照護一名接受輸血的病人，病人突然出現腰痛與血尿。下列何者為優先處置？
A nurse is caring for a client receiving a blood transfusion. The client suddenly develops flank pain and hematuria. Which action is the priority?
- ANotify the laboratory通知檢驗室
- BSlow the infusion rate減慢輸注速率
- CStop the transfusion immediately✓ 正解立即停止輸血
- DFlush the IV line with normal saline以生理食鹽水沖洗靜脈通路
— Explanation · 中文詳解 —
腰痛與血尿是急性溶血反應（Acute Hemolytic Reaction）的典型特徵，通常是因為血型不合導致。此時的首要原則是立即停止輸血，以減少後續輸入抗原，減輕免疫反應損傷。後續步驟為維持靜脈管路暢通（使用新的生理食鹽水）並緊急通知醫師。
Flank pain and hematuria are classic features of an acute hemolytic reaction, typically caused by ABO incompatibility. The first priority is to immediately stop the transfusion to prevent further antigen infusion and reduce ongoing immune-mediated damage. Subsequent steps include maintaining IV patency with new normal saline tubing and urgently notifying the physician.
✦ 台美臨床差異
台灣與美國輸血流程對於異常反應的處理 protocol 極為相似，皆強調立即停止與維護管路。