— 生理適應 · MEDIUM · MCQ —
護理師監測輸血時，病人在 15 分鐘後出現畏寒、發燒及下背痛。應優先採取何種措施？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, fever, and low back pain 15 minutes after the infusion starts. Which action is the priority?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BNotify the laboratory通知檢驗室
- CAdminister an antipyretic給予退燒藥
- DReduce the rate of infusion減慢輸注速率
— Explanation · 中文詳解 —
輸血過程中出現下背痛、畏寒與高熱，是急性溶血反應的典型徵象。此為致命性併發症，護理師應立即中斷輸血，使用新管路以生理食鹽水維持靜脈路徑，並保留血袋與管路送檢。切勿減速或嘗試退燒，應先移除輸血來源以減少進一步溶血。
Involving staff in the planning and decision-making process is the most effective strategy for managing resistance to change because it fosters a sense of ownership and reduces anxiety. Participative management transforms the change from a top-down mandate into a shared goal, thereby increasing buy-in and improving team cohesion compared to ignoring feedback or using coercive authority.
✦ 台美臨床差異
台美臨床 SOP 對於輸血反應的緊急處理流程高度一致，均強調「立即停止」與「生理食鹽水管路更換」。