— 降低風險 · HARD · MCQ —
護理師監測接受輸血的病人，病人出現寒顫、腰側疼痛及心跳過速，護理師應採取何種優先行動？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, flank pain, and tachycardia. What is the nurse's priority action?
- ANotify the laboratory通知實驗室
- BAdminister an antihistamine as ordered依醫囑給予抗組織胺
- CStop the transfusion immediately✓ 正解立即停止輸血
- DSlow the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
病人出現寒顫、腰痛和心跳過速，高度懷疑發生急性溶血性輸血反應（Acute Hemolytic Reaction）。這是危及生命的緊急情況，第一優先是立即停止輸血，並維持靜脈通路暢通，以生理食鹽水更換管路，並進行後續併發症監測。
The symptoms of chills, flank pain, and tachycardia suggest an acute hemolytic transfusion reaction, which is life-threatening. The nurse's priority action is to stop the transfusion immediately to prevent further hemolysis and administer normal saline to maintain venous access.
✦ 台美臨床差異
美台對輸血反應的緊急處理流程一致，均強調停止輸血並以生理食鹽水維持管路暢通。