— 降低風險 · MEDIUM · MCQ —
護理師評估一位正在輸血的病人，病人出現發燒、寒顫及腰痛。下列何者為優先護理措施？
A nurse is assessing a client receiving a blood transfusion. The client develops a fever, chills, and flank pain. Which is the priority nursing intervention?
- ASlow the rate of infusion減慢輸注速率
- BStop the transfusion immediately✓ 正解立即停止輸血
- CNotify the laboratory通知檢驗室
- DAdminister an antipyretic給付退燒藥
— Explanation · 中文詳解 —
發燒、寒顫及腰痛是急性溶血反應（Acute Hemolytic Transfusion Reaction）的典型特徵，通常是因為輸注了不相容的血液，導致受贈者體內的抗體攻擊捐贈者的紅血球，釋放大量的血紅素，造成腎小管損傷。這是致命的併發症，首要行動必須是立即停止輸血，並拔除管路，改以生理食鹽水維持靜脈路徑通暢。
Fever, chills, and flank pain indicate an acute hemolytic transfusion reaction, a life-threatening emergency caused by incompatible blood. The priority intervention is to immediately stop the transfusion to prevent further infusion of the offending agent. After stopping the infusion, the nurse should maintain IV access with saline and notify the provider.