— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師監測病人輸血過程，病人出現畏寒、下背痛與心跳過快。護理師首要行動為何？
A nurse is caring for a client receiving a blood transfusion. The client develops chills, lower back pain, and tachycardia. What is the nurse's priority action?
- AAdminister an antihistamine給予抗組織胺
- BSlow the infusion rate減慢輸注速率
- CStop the infusion immediately✓ 正解立即停止輸注
- DObtain a urine specimen取得尿液檢體
— Explanation · 中文詳解 —
此題情境為急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction），這是輸血中最危險的併發症之一。畏寒、下背痛與心跳過快是典型徵兆，起因於受贈者體內抗體攻擊捐贈者紅血球，導致溶血與腎小管阻塞。護理師首要行動必須是立即停止輸血，並維持靜脈管路暢通，以利後續給予生理食鹽水與搶救藥物。此為典型的 ABC（Airway, Breathing, Circulation）與安全性優先原則，嚴禁延遲處理。
Chills, lower back pain, and tachycardia suggest an acute hemolytic transfusion reaction, which is a medical emergency. The nurse's priority action is to stop the infusion immediately to prevent further harm, then maintain IV access with saline.
✦ 台美臨床差異
在美國臨床，發生反應後須立即取下輸血袋與管路，換上新的生理食鹽水管路以確保無殘留血液，並將血液袋送回血庫（Blood Bank）進行檢測，這與台灣標準作業程序一致。