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生理適應 · HARD · MCQ

病人於輸血過程中出現腰痛及血尿。護理師應採取的優先行動為何?

A client is receiving a blood transfusion and develops flank pain and hematuria. What is the nurse's priority action?

  • AInfuse normal saline
    輸注生理食鹽水
  • BCall the physician
    呼叫醫師
  • CObtain vital signs
    測量生命徵象
  • DStop the transfusion immediately✓ 正解
    立即停止輸血
Explanation · 中文詳解

腰痛與血尿是急性溶血反應的典型徵兆,代表紅血球破裂釋放出游離血紅素,可能導致急性腎損傷。根據輸血安全指引,一旦懷疑發生輸血反應,第一優先步驟絕對是停止輸血,以切斷過敏原或不相容抗原的輸入,接著維持管路通暢並通知醫療團隊。

Flank pain and hematuria are classic signs of an acute hemolytic transfusion reaction, which can lead to renal failure and shock. The priority nursing action is to stop the transfusion immediately to prevent further exposure to incompatible blood before notifying the provider or administering fluids.

✦ 台美臨床差異

台美兩地對輸血反應處理程序一致,皆強制規定第一時間立即停止輸血。

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