— 生理適應 · MEDIUM · MCQ —
對於接受輸血的病人，哪項評估最為優先？
Which of the following is a priority assessment for a client receiving a blood transfusion?
- AChecking the patient's room temperature檢查病人房間溫度
- BMeasuring urine output every 8 hours每 8 小時測量尿量
- CAssessing the patient's bowel sounds評估病人腸鳴音
- DMonitoring for signs of transfusion reaction✓ 正解監測輸血反應跡象
— Explanation · 中文詳解 —
輸血（Blood transfusion）屬於高風險護理操作，輸血反應（Transfusion reaction）可能在數分鐘內發生並迅速導致器官衰竭或死亡。護理師的優先任務是監測病人是否有發燒、冷顫、背痛、呼吸困難或紅疹等反應。臨床思路應遵循安全優先原則，隨時準備好發生反應時立即停止輸血並維持管路暢通。
Transfusion reactions can occur rapidly and lead to severe complications or death, making their early detection the highest priority. Nurses must continuously monitor for signs such as fever, chills, back pain, dyspnea, or rash during the infusion. Immediate recognition allows for prompt intervention, such as stopping the transfusion, to ensure client safety.
✦ 台美臨床差異
美國醫院對於輸血有極嚴格的雙人核對（Double-check）流程，且輸血開始前 15 分鐘必須在床邊進行嚴密監測，這在 NCLEX 考試中是必考重點。