— 降低風險 · HARD · MCQ —
護理師監測一位正在接受輸血的病人。病人出現寒顫、下背痛與心搏過速。護理師應採取的第一優先行動為何？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, lower back pain, and tachycardia. What is the nurse's priority action?
- AFlush the intravenous line with normal saline以正常生理食鹽水沖洗靜脈管路
- BAdminister an antipyretic medication給予解熱藥物
- CStop the transfusion and disconnect the tubing✓ 正解停止輸血並斷開管路
- DSlow the rate of the blood infusion減慢血液輸注速率
— Explanation · 中文詳解 —
輸血反應的護理原則是「停止、維持、通報」。當病人出現寒顫、下背痛（代表溶血導致腎小管阻塞）與心搏過速，這是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型特徵。護理師必須立即停止輸血，並以生理食鹽水維持管路暢通，以利後續急救用藥，不可僅降低速度或給藥。
The symptoms of chills, lower back pain, and tachycardia indicate an acute hemolytic transfusion reaction, which is a medical emergency. The nurse's priority action is to immediately stop the transfusion to prevent further hemolysis and administer normal saline to maintain IV access for potential resuscitation.
✦ 台美臨床差異
美國輸血規範中，輸血後的廢棄物處理與實驗室採樣（送回血袋與管路）程序非常嚴謹，護理師需確認醫院 Protocol 中是否有特定單位（如輸血醫學實驗室）的通知流程。