— 降低風險 · HARD · MCQ —
護理師照護一位正在輸血的病人，病人主訴背痛且畏寒。護理師應採取之優先行動為何？
A nurse is caring for a client who is receiving blood transfusion therapy. The client reports back pain and chills. Which action should the nurse take first?
- ANotify the physician通知醫師
- BObtain vital signs測量生命徵象
- CAdminister antipyretics給予解熱劑
- DStop the transfusion✓ 正解停止輸血
— Explanation · 中文詳解 —
背痛與畏寒是急性溶血性輸血反應的典型徵兆。護理師應立即停止輸血，確保病人的安全。隨後才更換管路並使用生理食鹽水維持靜脈路徑，最後通知醫師並送回血袋進行檢驗。停止輸血是防止輸液量持續擴大造成溶血反應惡化的關鍵步驟。
Back pain and chills are early signs of an acute hemolytic transfusion reaction, making it critical to stop the transfusion immediately to prevent further harm. After stopping the infusion, the nurse should maintain IV access with normal saline and notify the physician.
✦ 台美臨床差異
兩地輸血反應處理流程高度一致，皆強調「停止、通知、回報、檢驗」之標準化作業程序。