— 降低風險 · HARD · MCQ —
一位接受輸血的病人突然出現下背痛與寒顫。護理師的優先處置為何？
A nurse is caring for a client receiving blood transfusion. The client suddenly develops low back pain and chills. What is the nurse's priority action?
- AStop the transfusion immediately and disconnect the tubing✓ 正解立即停止輸血並斷開輸液管
- BAdminister an antihistamine as ordered依醫囑給予抗組織胺
- CSlow the infusion rate and assess vitals減慢輸注速度並評估生命徵象
- DIncrease the IV fluid rate with normal saline以生理食鹽水加快靜脈輸液速度
— Explanation · 中文詳解 —
下背痛與寒顫為急性溶血性輸血反應的典型徵兆。這是致命性的抗原抗體反應，處理原則為立即停止輸血，並以生理食鹽水更換管路以維持靜脈通道通暢，同時通知醫師並保留剩餘血袋。不可僅是減速或給藥，以免更多溶血反應發生。
Low back pain and chills are hallmark signs of an acute hemolytic transfusion reaction, which is life-threatening. The nurse must stop the transfusion immediately to prevent further infusion of incompatible blood and maintain IV access with normal saline while notifying the provider.
✦ 台美臨床差異
台美皆遵循「停、換、報」原則，且皆需回報輸血庫檢驗錯誤環節，這是在全球病安目標中均被強調的重點。