— 降低風險 · HARD · MCQ —
護理師照護一位接受輸血的病人。病人出現寒顫與發燒，護理師應採取的第一個行動為何？
A nurse is caring for a client receiving blood transfusion. The client develops chills and fever. What is the nurse's first action?
- AObtain a urine sample取得尿液樣本
- BNotify the physician通知醫師
- CStop the transfusion✓ 正解停止輸血
- DAdminister an antipyretic給予退燒藥
— Explanation · 中文詳解 —
輸血反應發生時，首要原則是立即停止輸血，以斷絕抗原抗體持續接觸。之後應以生理食鹽水維持靜脈管路通暢，並監測生命徵象、回報醫師及送回血袋與試管供檢驗。B、D、A 皆為後續處置，必須在移除輸血反應源後執行。
When a transfusion reaction occurs, the first principle is to stop the transfusion immediately to interrupt ongoing antigen-antibody exposure. Normal saline should then be infused to maintain IV patency, vital signs monitored, the physician notified, and the blood bag and tubing sent back for laboratory analysis. Options B, D, and A are follow-up actions that should only be performed after the source of the transfusion reaction has been removed.
✦ 台美臨床差異
輸血反應處理流程（STOP & REPORT）在兩地完全一致，皆強調即刻停止以確保病人安全。