— 生理適應 · MEDIUM · MCQ —
病患在接受輸血時出現寒顫與發燒。護理師的第一步行動為何？
A client is receiving a blood transfusion and develops chills and fever. What is the nurse's first action?
- ANotify the physician通知醫師
- BAdminister an antipyretic給予解熱劑
- CStop the transfusion immediately✓ 正解立即停止輸血
- DReduce the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
輸血反應如發燒、寒顫可能預示溶血性反應。護理師應先停止輸血以停止過敏原輸入，接著保持靜脈管路通暢（更換輸液管以避免繼續輸血），並通知醫師。D 選項無法解決抗原抗體反應。B 選項需在醫師評估過敏原因後再進行，非首要。
The nurse's first action when a client develops chills and fever during a transfusion is to stop the infusion immediately to prevent further exposure to the antigen. After stopping the transfusion, the nurse should maintain IV access with normal saline and notify the healthcare provider. Administering antipyretics or reducing the rate does not address the immediate need to halt the reaction.
✦ 台美臨床差異
美國醫院輸血監測 SOP 非常嚴格，護理師職權明確；台灣醫院對輸血反應的警覺性也很高，但系統化流程因院而異。