— 降低風險 · HARD · MCQ —
病人正在輸紅血球懸浮液（PRBCs），輸血 15 分鐘後出現畏寒、側腰痛與心搏過速。護理師應採取的第一個行動為何？
A client is receiving an IV infusion of packed red blood cells (PRBCs). The nurse notes the client develops chills, flank pain, and tachycardia 15 minutes after the start. Which action should the nurse take first?
- AObtain a urine specimen取得尿液檢體
- BAdminister antihistamines as prescribed依醫囑給予抗組織胺
- CStop the transfusion immediately✓ 正解立即停止輸血
- DSlow the rate of the blood transfusion減慢輸血速率
— Explanation · 中文詳解 —
輸血過程中出現畏寒、側腰痛與心搏過速，是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型徵兆，這是由於輸注了不相容的血液，導致受贈者的抗體攻擊捐贈者的紅血球，引發嚴重溶血。此反應可能迅速導致休克、急性腎衰竭甚至死亡。護理師的第一反應必須是「立即停止輸血」，並以生理食鹽水維持靜脈管路通暢，以便後續急救用藥，這是病人安全的最優先動作。
The client’s symptoms indicate an acute hemolytic transfusion reaction, a life-threatening emergency caused by incompatible blood. The nurse must immediately stop the transfusion to prevent further antigen-antibody interaction and maintain IV access with normal saline for emergency treatment.