— 生理適應 · EASY · MCQ —
病人在輸血前 15 分鐘內出現下背痛和發冷。護理師應先採取哪項行動？
A client is receiving a blood transfusion and reports lower back pain and chills within the first 15 minutes. Which action should the nurse take first?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BNotify the healthcare provider通知醫療提供者
- CSlow the rate of the transfusion減慢輸血速度
- DAdminister diphenhydramine as ordered依指示給予苯海拉明
— Explanation · 中文詳解 —
下背痛和發冷是急性溶血反應（Acute Hemolytic Reaction）的典型徵兆。輸血反應的首要處置永遠是「立即停止輸血」，改用生理食鹽水維持管路，以防止進一步的溶血和腎損傷。減慢速度（C）無效；通知醫師（B）是第二步。
Lower back pain and chills during a blood transfusion are signs of an acute hemolytic reaction, making it imperative to stop the transfusion immediately to prevent further harm. After stopping the infusion, the nurse should maintain IV access with normal saline and notify the healthcare provider. Slowing the rate is ineffective, and administering antihistamines is secondary to halting the exposure to incompatible blood.
✦ 台美臨床差異
無差異，停止輸血是全球通用的首要標準流程。