— 生理適應 · EASY · MCQ —
病人正在進行輸血，護理師觀察到病人出現發燒與寒顫。護理師首要行動為何？
A client is receiving a blood transfusion. The nurse notes the client has developed a fever and chills. What is the nurse's priority action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BAdminister an antipyretic給予解熱劑
- CNotify the laboratory通知檢驗室
- DReduce the rate of infusion減緩輸注速率
— Explanation · 中文詳解 —
輸血反應（Transfusion reaction）可能在輸血後短時間內發生，常見症狀包括發燒、寒顫、背痛、呼吸困難或低血壓。一旦觀察到發燒與寒顫，護理師的首要行動是立即停止輸血，以斷絕抗原抗體反應的來源，防止溶血加劇導致腎衰竭。隨後應以生理食鹽水維持靜脈通路（保持管路暢通），更換輸液管，並通知醫師與血庫進行後續處理。
The nurse must immediately stop the transfusion to prevent further antigen-antibody reactions and potential hemolysis. After stopping the infusion, the nurse should maintain venous access with normal saline and notify the healthcare provider and blood bank.