— 降低風險 · HARD · MCQ —
護理師照顧一位正在輸血的病人。病人出現寒顫、腰痛與心搏過速。護理師的優先處置為何？
A nurse is providing care to a client receiving a blood transfusion. The client develops chills, flank pain, and tachycardia. What is the nurse's priority action?
- AAdminister an antihistamine給予抗組織胺
- BStop the transfusion immediately✓ 正解立即停止輸血
- CNotify the laboratory通知檢驗室
- DSlow the rate of the blood transfusion減慢輸血速度
— Explanation · 中文詳解 —
寒顫、腰痛與心搏過速是急性溶血反應（Acute Hemolytic Transfusion Reaction）的典型症狀。這是輸血反應中最危險的一種，必須立即停止輸血，確保靜脈管路暢通（更換管路並給予生理食鹽水），通知醫師，並送回血液檢體及輸血記錄單。減慢速度（選項 D）無法減輕溶血造成的嚴重後果。
Chills, flank pain, and tachycardia are classic signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse's priority action is to stop the transfusion immediately to prevent further harm, followed by maintaining IV access with saline and notifying the provider.
✦ 台美臨床差異
兩地針對輸血反應的緊急處理流程（Stop, Maintain line, Notify）在標準化作業程序中完全一致，均強調第一時間排除致病來源。