— 降低風險 · HARD · MCQ —
病人正在接受輸血，隨後出現腰部疼痛及發燒。下列何者為優先行動？
A client is receiving a blood transfusion and develops flank pain and fever. Which action is the priority?
- ASlow the transfusion rate減慢輸血速度
- BObtain a urine sample取得尿液樣本
- CAdminister acetaminophen給予乙醯胺酚
- DStop the transfusion immediately✓ 正解立即停止輸血
— Explanation · 中文詳解 —
腰部疼痛、發燒、寒顫、血尿及低血壓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。這是危及生命的緊急狀況，護理師應遵循「停止輸血、維持靜脈通路、通知醫師」的標準處置程序，防止溶血進一步導致腎衰竭與瀰漫性血管內凝血（DIC）。
Flank pain and fever indicate an acute hemolytic transfusion reaction, a life-threatening emergency caused by ABO incompatibility. The nurse must immediately stop the transfusion to prevent further hemolysis and subsequent complications such as renal failure or disseminated intravascular coagulation (DIC).
✦ 台美臨床差異
台美臨床對於輸血反應的處置一致，皆遵循「停止輸血、更換點滴管路（使用生理食鹽水維持管路）、通知醫師」的標準程序（Standard of Care），確保不會誤將管路中剩餘的血液輸入體內。