— 降低風險 · HARD · MCQ —
病人正在輸血，突然出現畏寒、側腹疼痛與心跳過速。護理師的優先行動為何？
A client is receiving a blood transfusion and develops sudden chills, flank pain, and tachycardia. What is the nurse's priority action?
- AAdminister an antihistamine as ordered依指示給予抗組織胺
- BStop the transfusion and disconnect the tubing✓ 正解停止輸血並斷開管路
- CNotify the laboratory to re-verify crossmatch通知實驗室重新確認交叉配血
- DSlow the rate of the transfusion減慢輸血速度
— Explanation · 中文詳解 —
畏寒、側腹疼痛（Flank pain）與心跳過速是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型症狀，這是由於輸血不相容導致紅血球被大量破壞，釋放出的血紅素會阻塞腎小管，導致急性腎衰竭甚至死亡。護理師的首要行動必須是立即停止輸血，並拔除管路，以避免更多過敏原或不相容血液進入體內。
Chills, flank pain, and tachycardia are classic manifestations of an acute hemolytic transfusion reaction caused by incompatible blood, in which massive red cell destruction releases hemoglobin that can obstruct the renal tubules and lead to acute renal failure or death. The nurse's immediate priority is to stop the transfusion and disconnect the tubing to prevent any additional incompatible blood from entering the body.