— 降低風險 · HARD · MCQ —
護理師監測接受輸血的病患，病患出現畏寒、下背痛及心搏過速。下列何者為優先處置？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, low back pain, and tachycardia. Which action is the priority?
- ASlow the rate of the transfusion減慢輸血速率
- BAdminister the prescribed antipyretic給予處方的解熱劑
- CStop the transfusion immediately✓ 正解立即停止輸血
- DNotify the health care provider通知醫療提供者
— Explanation · 中文詳解 —
畏寒、下背痛與心搏過速是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型特徵，通常由 ABO 血型不合引起。這是危及生命的醫療急症。護理師的第一優先行動是立即停止輸血，更換輸液管並以生理食鹽水維持靜脈通暢，以防殘餘血液繼續輸入體內，隨後再通知醫師與採取後續支持性治療。
Chills, low back pain, and tachycardia indicate an acute hemolytic transfusion reaction, a medical emergency caused by incompatible blood types. The nurse's priority action is to stop the transfusion immediately to prevent further hemolysis and notify the healthcare provider.