— 降低風險 · HARD · MCQ —
一位病人正在接受輸血。護理師觀察到病人出現寒顫、腰痛與低血壓。護理師的優先處置為何？
A client is receiving a blood transfusion. The nurse notes the client has developed chills, flank pain, and hypotension. What is the nurse's priority action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BSlow the infusion rate減慢輸注速率
- CAssess the client's temperature評估病人的體溫
- DAdminister an antihistamine給予抗組織胺
— Explanation · 中文詳解 —
寒顫、腰痛與低血壓是典型的「急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）」，這是由於 ABO 血型不合引起的嚴重免疫反應，可能導致腎衰竭與休克，危及生命。護理師必須立即停止輸血，確保病人安全，接著更換管路並通知醫師。這是輸血過程中必須優先處理的緊急狀況。
Chills, flank pain, and hypotension indicate an acute hemolytic transfusion reaction, a life-threatening emergency caused by ABO incompatibility. The nurse's priority action is to immediately stop the transfusion to prevent further harm, then maintain IV access with normal saline and notify the provider.