護理師正在為病人進行濃縮紅血球輸注,病人出現寒顫、腰痛與心搏過速。護理師應採取哪些行動?(選所有適合的)
A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. The client develops chills, flank pain, and tachycardia. Which actions should the nurse perform? (Select all that apply.)
- AStop the transfusion immediately✓ 正解立即停止輸血
- BKeep the vein open with normal saline✓ 正解以生理食鹽水保持靜脈通路開放
- CSlow the infusion rate to minimal將輸注速率減慢至最低
- DNotify the healthcare provider✓ 正解通知醫療保健提供者
- ESend the blood bag and tubing to the lab✓ 正解將血袋和輸血管路送至實驗室
病人出現寒顫、腰痛與心搏過速,此為典型的急性溶血性輸血反應(Acute Hemolytic Transfusion Reaction),通常源於 ABO 不相容。這是醫療緊急情況,處理原則為:第一,立即停止輸血(Stop transfusion);第二,用新的生理食鹽水維持靜脈管路通暢,以利後續藥物給予;第三,通知醫師;第四,回收所有血品及管路送檢,以利實驗室分析反應原因。
The client is experiencing an acute hemolytic transfusion reaction, a medical emergency caused by ABO incompatibility. The nurse must immediately stop the transfusion to prevent further harm, maintain IV access with normal saline for emergency medications, notify the healthcare provider, and send the blood bag and tubing to the laboratory for analysis.