— 降低風險 · MEDIUM · MCQ —
護理師評估一位正在輸血的病人，病人出現發燒、寒顫及腰痛。護理師的優先處置為何？
A nurse is assessing a client receiving a blood transfusion. The client develops a fever, chills, and flank pain. What is the nurse's priority action?
- ANotify the laboratory of the reaction通知實驗室該反應
- BSlow the rate of the transfusion減慢輸血速率
- CAdminister acetaminophen as ordered依醫囑給予乙醯胺酚
- DDisconnect the blood tubing and infuse normal saline✓ 正解斷開輸血管路並輸注生理食鹽水
— Explanation · 中文詳解 —
上述症狀高度懷疑為急性溶血性輸血反應。一旦發生，首要行動是立即停止輸血並拔除輸血管路，使用全新的輸液管路給予生理食鹽水，以維持血管通路及保持血壓。此舉是為了阻斷輸血反應的持續發生，並保留血液樣品以供後續檢驗分析。
These symptoms are highly suggestive of an acute hemolytic transfusion reaction. Once it occurs, the immediate action is to stop the transfusion and disconnect the blood tubing, and to administer normal saline using a new IV tubing set to maintain venous access and support blood pressure. This is done both to interrupt the ongoing transfusion reaction and to preserve blood samples for subsequent laboratory analysis.
✦ 台美臨床差異
台美皆視溶血為緊急事件，但美國執業中對於輸血反應後管路保留與送檢流程有極嚴格的 protocol。