— 降低風險 · MEDIUM · MCQ —
護理師照護一位接受輸血的病人。病人開始出現蕁麻疹並主訴搔癢。護理師首要採取哪項行動？
A nurse is caring for a client who is receiving a blood transfusion. The nurse notices the client begins to develop hives and reports itching. What should be the nurse's first action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BAdminister antihistamines給予抗組織胺
- CSlow the rate of the transfusion減慢輸血速度
- DNotify the laboratory通知檢驗室
— Explanation · 中文詳解 —
輸血反應一出現（如蕁麻疹、搔癢），首要任務是停止輸血，以切斷過敏原輸入。隨後應更換管路並以生理鹽水維持靜脈通暢，立即通知醫師，並將血袋與管路送回檢驗室進行分析。不可僅是減緩速度，因為這會持續暴露病人於過敏原之下。
The priority action when signs of an allergic reaction, such as hives and itching, occur during a blood transfusion is to stop the infusion immediately to prevent further exposure to the allergen. After stopping the transfusion, the nurse should maintain IV access with normal saline, notify the healthcare provider, and return the blood product and tubing to the laboratory for analysis.
✦ 台美臨床差異
台美臨床對於輸血不良反應的標準處置程序（SOP）高度一致，皆視為優先級極高的緊急事項。