— 降低風險 · HARD · SATA —
護理師評估一位正在輸血的病人，病人主訴寒顫、下背痛及心跳過速。護理師應先執行哪些措施？（複選）
A nurse is assessing a client receiving a blood transfusion. The client reports chills, low back pain, and tachycardia. Which of the following should the nurse do first? (Select all that apply.)
- AStop the transfusion immediately✓ 正解立即停止輸血
- BInfuse 0.9% normal saline through a new tubing✓ 正解通過新管路輸注 0.9% 生理食鹽水
- CNotify the provider✓ 正解通知醫師
- DSend the blood bag and tubing back to the lab✓ 正解將血袋和管路送回實驗室
- EAdminister acetaminophen as ordered依醫囑給予乙醯胺酚
— Explanation · 中文詳解 —
病人的症狀（寒顫、背痛、心跳快）高度懷疑為溶血性輸血反應。處理原則為立即停止輸血、維持靜脈路徑（用新管路給生理食鹽水）、通知醫師、並將檢體與血袋送回檢驗科供確認。給予退燒藥是症狀治療，並非緊急處理的第一步。
The nurse must first stop the transfusion immediately to prevent further infusion of incompatible blood. Next, the nurse should infuse 0.9% normal saline through new tubing to maintain vascular access without introducing more antigen. The provider must be notified promptly, and the blood bag and tubing should be sent to the lab for post-transfusion testing to confirm the reaction.
✦ 台美臨床差異
台美皆嚴格遵循輸血反應處理指引，但台灣病房內通報流程多依賴護理師直接聯繫主治醫師或住院醫師。