— 生理適應 · MEDIUM · MCQ —
護理師監測輸血過程，病人於輸血 15 分鐘後出現畏寒、發燒與下背痛。護理師優先採取的行動為何？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, fever, and low back pain 15 minutes after the transfusion begins. What is the nurse's priority action?
- AAdminister acetaminophen as ordered依指示給予乙醯胺酚
- BStop the transfusion immediately✓ 正解立即停止輸血
- CFlush the tubing with normal saline以生理食鹽水沖洗管路
- DSlow the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
出現畏寒、發燒、下背痛是急性溶血反應（Acute Hemolytic Reaction）的典型特徵，這是致命的併發症。首要任務是立刻停止輸血，拔除血袋與管路，並維持靜脈通路暢通，以利後續急救用藥與輸液處置。
Chills, fever, and low back pain shortly after starting a transfusion indicate an acute hemolytic reaction, which is a life-threatening emergency. The nurse must immediately stop the transfusion to prevent further exposure to incompatible blood. Maintaining IV access with normal saline is critical for administering emergency treatments.
✦ 台美臨床差異
台美臨床對溶血反應的處置流程幾乎一致，皆強調停止輸血並以新管路維持生命徵象穩定。