— 降低風險 · HARD · MCQ —
一位接受輸血的病人出現寒顫、腰痛與發燒。護理師應採取的優先行動為何？
A nurse is caring for a client receiving a blood transfusion. The client develops chills, flank pain, and fever. What is the priority action?
- ASlow the rate of the transfusion減慢輸血速度
- BDisconnect the blood tubing and infuse normal saline✓ 正解斷開輸血管路並輸注生理食盐水
- CAdminister an antipyretic給予退燒藥
- DObtain a urine sample採集尿液樣本
— Explanation · 中文詳解 —
症狀顯示病人發生了嚴重的急性溶血性輸血反應。第一時間必須立即停止輸血，並更換點滴管路，以維持生理食鹽水通暢，防止血液成分繼續進入循環，同時回報醫療團隊。給予退燒藥或減緩速度已不足以處理此類嚴重反應，留取尿液雖是後續必要程序，但優先順序排在移除致敏源之後。
The priority action when a client exhibits signs of an acute hemolytic transfusion reaction, such as chills, flank pain, and fever, is to immediately stop the transfusion. The nurse should disconnect the blood tubing and infuse normal saline to maintain venous access, as continuing the transfusion even at a slower rate could lead to severe hemodynamic collapse.
✦ 台美臨床差異
兩地臨床輸血反應處理指引一致，皆遵循『立即停止、維持靜脈通路、通知醫師』的嚴格安全流程。