— 藥理與非經腸給藥 · HARD · MCQ —
一位接受輸血的病人出現寒顫、腰痛及低血壓，護理師應優先採取何種行動？
A nurse is caring for a client receiving a blood transfusion. The client develops chills, flank pain, and hypotension. Which action should the nurse take first?
- AAdminister an antihistamine給予抗組織胺
- BNotify the physician通知醫師
- CSlow the infusion rate減慢輸注速率
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
輸血過程中出現寒顫、腰痛（腎臟受損跡象）與低血壓，是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型特徵，通常是由於 ABO 血型不合引起的。這屬於致命性緊急狀況，優先處理順序為：立即停止輸血，更換輸液管路並以生理食鹽水維持靜脈通路，以維持血壓並保護腎臟功能，隨後通知醫師並送回血袋與病人血液檢驗。
Chills, flank pain, and hypotension are classic signs of an acute hemolytic transfusion reaction, a medical emergency often caused by ABO incompatibility. The nurse's priority action is to stop the transfusion immediately to prevent further hemolysis and renal damage, then maintain IV access with normal saline while notifying the provider.