— 生理適應 · HARD · MCQ —
護理師照護一名輸血病人，病人突然主訴下背痛及寒顫。護理師應立即採取的行動為何？
A nurse is caring for a client receiving a blood transfusion. The client suddenly reports lower back pain and chills. Which action should the nurse take immediately?
- AObtain vital signs to confirm a fever測量生命徵象以確認發燒
- BSlow the rate of the transfusion減慢輸血速率
- CAdminister an antipyretic給藥解熱劑
- DStop the transfusion and disconnect the tubing✓ 正解停止輸血並斷開管路
— Explanation · 中文詳解 —
輸血反應中，下背痛（腰痛）是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型特徵，這是因為抗原抗體反應導致紅血球溶血，游離血紅素阻塞腎小管。護理師的第一優先行動（Priority Action）是立即停止輸血並切斷輸血管路，以阻斷過敏原或致病因子的輸入。接著必須更換新的管路並以生理食鹽水維持靜脈通路（Keep Vein Open, KVO），以利後續急救藥物給予。
Lower back pain and chills during a blood transfusion are classic signs of an acute hemolytic transfusion reaction caused by incompatible blood. The nurse must immediately stop the transfusion and disconnect the tubing to prevent further infusion of incompatible red blood cells, then maintain IV access with normal saline.