— 降低風險 · HARD · MCQ —
輸血過程中，病人出現畏寒、下背痛及心搏過速。護理師首要採取的措施為何？
A nurse is caring for a client receiving blood transfusion who develops chills, low back pain, and tachycardia. Which is the priority action?
- ASlow the rate of infusion and monitor vitals減慢輸注速度並監測生命徵象
- BStop the transfusion immediately✓ 正解立即停止輸血
- CAdminister an antipyretic as ordered依醫囑給予解熱劑
- DCollect a urine specimen for analysis收集尿液樣本進行檢驗
— Explanation · 中文詳解 —
輸血反應（Transfusion reaction）中的畏寒、下背痛與心搏過速是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型特徵，通常由 ABO 血型不合引起。這是一種致命性的緊急狀況，紅血球破裂釋放的血紅素會導致急性腎衰竭與休克。護理師必須立刻停止輸血，並以生理食鹽水維持管路通暢，以保護腎臟灌流，這是護理處置的絕對優先事項。
Chills, low back pain, and tachycardia indicate an acute hemolytic transfusion reaction, a life-threatening emergency caused by incompatible blood types. The priority action is to immediately stop the transfusion to prevent further red blood cell destruction and potential renal failure.