— 降低風險 · MEDIUM · MCQ —
病人出現輸血反應，優先的護理措施為何？
A client is experiencing a transfusion reaction. What is the priority nursing intervention?
- ANotify the physician通知醫師
- BSlow the rate of infusion減慢輸注速率
- CStop the infusion immediately✓ 正解立即停止輸注
- DObtain vital signs測量生命徵象
— Explanation · 中文詳解 —
輸血反應一發生，第一步就是切斷血源，終止輸入任何血製品，以減少過敏原或致敏抗原繼續進入循環系統。之後才換上生理食鹽水維持管路通暢，並通知醫師。Vital signs（D）是後續評估步驟，但斷開血袋是首要動作。
The priority intervention during a transfusion reaction is to stop the infusion immediately to prevent further exposure to the offending antigen. After discontinuing the blood product, the nurse should maintain venous access with normal saline, assess vital signs, and notify the healthcare provider.
✦ 台美臨床差異
美台皆將『停輸血、更換食鹽水、通知醫師』作為輸血反應處理的標準處置流程（Standard Protocol）。