— 降低風險 · MEDIUM · MCQ —
一位接受輸血的病人突然出現腰痛、發燒及寒顫。護理師應優先採取什麼行動？
A nurse is caring for a client receiving a blood transfusion. The client suddenly 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
- BObtain a urine sample取得尿液樣本
- CCall the physician通知醫師
- DSlow the transfusion rate減慢輸血速率
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute hemolytic transfusion reaction）是致命的緊急情況，通常在輸血後幾分鐘內發生，症狀包括腰痛、發燒、寒顫、血紅素尿與低血壓。護理師必須立刻停止輸血，確保病人生命徵象穩定，並更換靜脈管路以生理食鹽水維持通路，同時保留血袋與管路送驗，這是標準的輸血安全流程。
The nurse’s first action is to stop the transfusion immediately because the symptoms indicate a potentially fatal acute hemolytic reaction. Continuing the infusion, even at a slower rate, exposes the client to further harm from incompatible blood. After stopping the transfusion, the nurse should maintain IV access with saline and notify the provider, but cessation is the critical priority.