— 降低風險 · HARD · MCQ —
病人輸血後出現體溫升高、心搏過速及低血壓。護理師應先採取哪項行動？
A client presents with an elevated temperature, tachycardia, and hypotension after a blood transfusion. Which action should the nurse take first?
- ANotify the healthcare provider通知醫療提供者
- BObtain a urine specimen取得尿液標本
- CStop the transfusion immediately✓ 正解立即停止輸血
- DAdminister an antipyretic給予解熱劑
— Explanation · 中文詳解 —
輸血後出現發燒、低血壓、心搏過速，強烈懷疑為急性溶血性輸血反應。首要原則是立即停止輸血（Stop the transfusion），斷開輸血管路並以生理食鹽水維持靜脈管路通暢，隨後才是後續的藥物處理與回報。
When signs of an acute hemolytic transfusion reaction such as fever, tachycardia, and hypotension appear, the nurse must immediately stop the transfusion to prevent further infusion of incompatible blood. Subsequent actions include maintaining IV access with saline and notifying the provider.
✦ 台美臨床差異
輸血反應處置流程國際一致，但台灣護理師需同時嚴格執行回報血庫程序。