— 降低風險 · HARD · MCQ —
護理師為病人輸血時，病人出現寒顫、腰痛及低血壓，應優先採取什麼行動？
A nurse is assessing a client receiving a blood transfusion. The client develops chills, flank pain, and hypotension. Which action is the priority?
- AObtain a blood sample for lab testing抽取血液樣本送驗
- BNotify the physician immediately立即通知醫師
- CSlow the infusion rate減緩輸注速度
- DDisconnect the blood tubing✓ 正解斷開輸血管路
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）多發生於輸血後數分鐘內，原因通常是ABO血型不合。病人的症狀（寒顫、腰痛、低血壓）顯示紅血球大量破裂，導致腎衰竭風險。第一優先行動是立即停止輸血，並以生理食鹽水維持管路暢通，以利後續急救用藥，並保留剩餘血液送檢以確認反應原因。
The symptoms of chills, flank pain, and hypotension indicate an acute hemolytic transfusion reaction, likely caused by ABO incompatibility, which poses a high risk for renal failure. The priority action is to immediately stop the transfusion by disconnecting the tubing to prevent further hemolysis and maintain IV access with saline.
✦ 台美臨床差異
美國護理指引中，輸血反應發生時，護理師需立即更換輸液管路並以生理食鹽水（Normal Saline）維持管路通暢，這點在NCLEX考題中極為重要。