— 降低風險 · HARD · MCQ —
一位正在接受輸血的病人出現發燒、寒顫及腰痛。護理師應優先採取哪項措施？
A nurse is assessing a client receiving a blood transfusion who develops fever, chills, and flank pain. Which action should the nurse take first?
- ACheck the client's vital signs測量病人生命徵象
- BStop the transfusion immediately✓ 正解立即停止輸血
- CNotify the laboratory通知檢驗室
- DAdminister acetaminophen as ordered依醫囑給予乙醯胺酚
— Explanation · 中文詳解 —
病人出現發燒、寒顫及腰痛是急性溶血性輸血反應的典型徵兆。這是致命的免疫反應，護理師必須立刻停止輸血，以切斷抗原-抗體反應源。接著維持靜脈管路通暢，更換全新輸液套管並以生理食鹽水緩慢灌注，再通知醫師並回傳血袋與管路進行檢驗。
The client is exhibiting classic signs of an acute hemolytic transfusion reaction, which is a life-threatening immune response. The nurse must immediately stop the transfusion to prevent further exposure to incompatible antigens. After stopping the infusion, the nurse should maintain IV access with normal saline and notify the provider.
✦ 台美臨床差異
台灣輸血反應通報流程涉及嚴謹的血液庫抽血與檢體回送，與美國標準作業流程（SOP）高度相似。