— 降低風險 · HARD · MCQ —
護理師照顧一位正進行輸血的病人，病人出現畏寒、下背痛及心搏過速。護理師應優先採取的行動是什麼？
A nurse is caring for a client receiving a blood transfusion. The client begins to report chills, low back pain, and tachycardia. What is the nurse's priority action?
- ASlow the rate of infusion減慢輸注速率
- BNotify the laboratory通知檢驗科
- CAdminister an antipyretic給予解熱劑
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
畏寒、下背痛與心搏過速是急性溶血性輸血反應（Acute hemolytic transfusion reaction）的典型徵兆，通常是因為血型不合導致。這會引發嚴重的腎衰竭與休克，優先行動必須是「立即停止輸血（Stop transfusion）」，並更換輸血管路，以生理食鹽水維持靜脈路徑，避免殘留血液繼續輸注。
Chills, low back pain, and tachycardia are classic signs of an acute hemolytic transfusion reaction caused by incompatible blood types. The nurse's priority action is to immediately stop the transfusion to prevent further infusion of incompatible red blood cells, which can lead to severe renal failure and shock.