— 生理適應 · HARD · MCQ —
病患在接受輸血時出現寒顫、腰痛與低血壓，護理師應採取之優先措施為何？
A client is receiving a blood transfusion and develops chills, flank pain, and hypotension. What is the priority nursing action?
- AAdminister diphenhydramine給予苯海拉明
- BNotify the provider通知醫師
- CSlow the rate of transfusion減慢輸血速度
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
病患出現寒顫、腰痛與低血壓，顯示發生了急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）。首要步驟是立即停止輸血，切斷輸注源，並以生理食鹽水維持管路通暢，確保後續急救用藥需求。
The patient presents with chills, back pain, and hypotension, indicating an acute hemolytic transfusion reaction. The first step is to stop the transfusion immediately, cut off the infusion source, and maintain line patency with normal saline to support subsequent emergency medication needs.
✦ 台美臨床差異
兩國對於輸血反應的緊急處理流程極為相似，皆強調「停、通、報」原則。