— 降低風險 · HARD · MCQ —
病人正在進行輸血，隨後出現腰痛、發燒與寒顫。護理師的首要行動為何？
A client is receiving a blood transfusion and develops flank pain, fever, and chills. What is the nurse's first action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BNotify the healthcare provider通知醫療提供者
- CSlow the transfusion rate減慢輸血速率
- DObtain a urine sample取得尿液樣本
— Explanation · 中文詳解 —
上述症狀（腰痛、發燒、寒顫）是急性溶血反應（Acute Hemolytic Reaction）的典型特徵。第一步永遠是停止輸血，並維持靜脈導管通暢（換上新的管路與生理食鹽水）以備急救，防止溶血反應持續惡化導致腎衰竭。
Flank pain, fever, and chills are classic signs of an acute hemolytic transfusion reaction. The nurse's priority action is to stop the transfusion immediately to prevent further exposure to incompatible blood and mitigate the risk of renal failure or shock.
✦ 台美臨床差異
輸血反應處置標準化程度高，台灣亦遵循停止輸血、維持靜脈通路、通知醫師並將血袋送回檢驗科的 SOP。