— 降低風險 · HARD · MCQ —
一位病人正在接受輸血，輸血開始 15 分鐘後出現腰痛、發燒及寒顫。護理師應採取的首要行動為何？
A client is receiving a blood transfusion. The nurse notes the client develops flank pain, fever, and chills 15 minutes after the transfusion begins. What is the nurse's first action?
- AAdminister an antipyretic給予解熱劑
- BStop the blood transfusion✓ 正解停止輸血
- CFlush the tubing with normal saline用生理食鹽水沖洗管路
- DNotify the physician immediately立即通知醫師
— Explanation · 中文詳解 —
輸血出現腰痛、發燒、寒顫，極可能是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction），這是由於 ABO 不相容導致紅血球破壞，釋放出的血紅素會阻塞腎小管，導致急性腎衰竭甚至死亡。護理師的首要行動是立即停止輸血，以截斷抗原-抗體反應，接著以生理食鹽水維持管路暢通，並通知醫師與輸血服務中心。
Flank pain, fever, and chills shortly after starting a transfusion suggest an acute hemolytic reaction caused by ABO incompatibility. The nurse’s first action must be to stop the transfusion immediately to prevent further hemolysis and potential renal failure. After stopping the infusion, the nurse should maintain IV access with normal saline and notify the physician.