— 生理適應 · MEDIUM · MCQ —
接受輸血的病人，哪項評估最為關鍵？
Which of the following assessments would be most critical for a client receiving a blood transfusion?
- AMonitoring for chills, fever, or rash✓ 正解監測是否有畏寒、發燒或皮疹
- BVerifying the blood type with another nurse與另一位護理師核對血型
- CChecking the expiration date of the blood bag檢查血袋的有效期
- DAssessing the client's hemoglobin level before transfusion在輸血前評估病人的血紅素水平
— Explanation · 中文詳解 —
輸血反應（Transfusion reaction）可能在輸血後數分鐘內發生，危及生命。急性溶血反應、過敏反應或發熱性非溶血反應常表現為寒顫、發燒、蕁麻疹、腰痛或呼吸困難。護理師在輸血過程中必須持續密切監測生命徵象，一旦發現異常，必須立即停止輸血，維持靜脈通路，並通知醫師。這是護理師在輸血護理中最關鍵的臨床責任。
Monitoring for signs of transfusion reactions, such as chills, fever, or rash, is the most critical ongoing assessment because these reactions can occur rapidly and be fatal. Although verification and expiration checks are essential preparatory steps, continuous clinical monitoring during the infusion is the nurse's primary responsibility to ensure patient safety.