— 生理適應 · EASY · MCQ —
病人正在進行輸血，護理師觀察到 15 分鐘後出現腰痛、發冷與心搏過速。最正確的處置為何？
A client is undergoing a blood transfusion. The nurse notes the client develops flank pain, chills, and tachycardia 15 minutes after initiation. Which is the most appropriate action?
- ANotify the laboratory to re-type the blood通知實驗室重新配血
- BAdminister an antihistamine per standing order依常規醫回給予抗組織胺
- CStop the transfusion immediately and disconnect the tubing✓ 正解立即停止輸血並斷開輸液管路
- DSlow the infusion rate減慢輸注速度
— Explanation · 中文詳解 —
出現腰痛、發冷、心搏過速是急性溶血性反應（Acute Hemolytic Reaction）的典型特徵。這是致命的免疫反應，首要任務是停止輸血，並更換輸液管路使用生理食鹽水維持靜脈通路，而非僅僅減慢速度或給予藥物。後續需回報醫師並採取維持腎灌流的措施。
The client is exhibiting signs of an acute hemolytic reaction, a life-threatening immune response to incompatible blood. The priority nursing action is to immediately stop the transfusion and disconnect the tubing to prevent further exposure to the incompatible blood.
✦ 台美臨床差異
美台臨床對於輸血反應的緊急處理流程高度一致，皆以立即停止與維持生理食鹽水通路為核心。