病人正在進行輸血,突然出現畏寒與發燒,下列何者為優先護理措施?
A nurse is caring for a client receiving blood transfusion. The client develops chills and fever. What is the priority nursing action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BSlow the rate of transfusion減緩輸血速率
- CObtain a blood culture抽取血液培養
- DAdminister an antipyretic給予退燒藥
輸血反應(Transfusion Reactions)是指病人輸血過程中或輸血後發生的不良反應,可能從輕微到危及生命。發燒(Fever)和畏寒(Chills)是最常見的輸血反應症狀之一,可能表示身體對輸入的血液產生免疫反應(如溶血性輸血反應 Hemolytic Transfusion Reaction)或血液受到細菌污染(如敗血性輸血反應 Septic Transfusion Reaction)。 核心原則是「立即停止潛在危險因素」,以防止情況惡化。在出現疑似輸血反應的症狀時,首要且最緊急的護理措施是立即停止輸血(Stop the transfusion immediately)。這是為了阻止任何殘餘的血液繼續進入病體循環,進一步加劇不良反應。 選項 B(減緩輸血速率)是不正確的。雖然在某些情況下可能需要調整速率,但出現發燒和畏寒等急性反應時,停止輸血才是首要步驟,僅減緩速率不足以確保安全。選項 D(給予退燒藥)和 C(抽取血培養)雖然是後續處理的一部分,但必須在停止輸血之後進行。必須先移除問題源頭(輸血),才能進行其他評估與治療。
The priority nursing action when a client exhibits signs of a transfusion reaction, such as chills and fever, is to stop the transfusion immediately to prevent further infusion of the offending agent. Slowing the rate or administering antipyretics before stopping the transfusion delays critical intervention and may worsen the reaction. Diagnostic steps like obtaining cultures or treating symptoms should only occur after the transfusion has been halted and the tubing changed.