— 生理適應 · MEDIUM · MCQ —
病人正在輸血,並主訴腰痛和發冷。首要護理行動是什麼?
A client is receiving a blood transfusion and reports low back pain and chills. What is the priority nursing action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BNotify the physician通知醫師
- CSlow the infusion rate減慢輸注速度
- DAdminister acetaminophen給予乙醯胺酚
— Explanation · 中文詳解 —
本題的核心概念是識別輸血反應的早期徵兆並採取即時的護理行動。輸血反應,特別是急性溶血性輸血反應(acute hemolytic transfusion reaction),是一種嚴重的、可能危及生命的併發症,通常在輸注不相容血液後迅速發生。腰痛(low back pain)和發冷(chills)是急性溶血反應的典型初期症狀。一旦懷疑發生輸血反應,護理師的首要任務是立即停止輸血,以防止更多的不相容血液進入病患體內,從而限制反應的嚴重程度和潛在的器官損傷。
Low back pain and chills are early signs of an acute hemolytic transfusion reaction, which is a medical emergency. The priority nursing action is to immediately stop the transfusion to prevent further administration of incompatible blood.
✦ 台美臨床差異
美國規範要求將剩餘血袋與管路送回實驗室;台灣流程一致,但行政通報系統各院有別。