— 生理適應 · MEDIUM · MCQ —
病人接受輸血時出現腰痛、寒顫與發燒。護理師的優先處置為何?
A client is receiving a blood transfusion and develops flank pain, chills, and fever. What is the nurse's priority action?
- ANotify the laboratory通知檢驗室
- BSlow the infusion rate減慢輸注速率
- CAdminister an antipyretic給予退燒藥
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
輸血過程中出現腰痛、寒顫、發燒是急性溶血性輸血反應(Acute hemolytic transfusion reaction)的典型徵兆,這屬於危及生命的緊急情況。護理師必須立即停止輸血,並使用生理食鹽水保持靜脈通路暢通(Keep vein open),以維持血管通路並稀釋殘留的溶血成分。此為護理作業中保障病人生命安全的最高優先級(Priority)。
Flank pain, chills, and fever are hallmark signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse's priority action is to immediately stop the transfusion to prevent further introduction of incompatible blood, then maintain IV access with normal saline to support circulation and renal function.