— 降低風險 · HARD · MCQ —
護理師監測正在接受輸血的病人。病人出現畏寒、側腹痛與低血壓，護理師的首要行動為何？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, flank pain, and hypotension. What is the nurse's priority action?
- ANotify the laboratory通知檢驗科
- BSlow the infusion rate減慢輸注速率
- CStop the transfusion immediately✓ 正解立即停止輸血
- DAdminister an antihistamine給予抗組織胺
— Explanation · 中文詳解 —
畏寒、側腹痛與低血壓是典型的急性溶血性輸血反應（Acute hemolytic transfusion reaction），通常源於 ABO 血型不合。當出現這些症狀，護理師的首要行動是立即停止輸血，以阻斷抗原-抗體反應。接著需更換輸血管路，以生理食鹽水維持靜脈路徑暢通，並通知醫師及檢驗科進行後續調查。此為攸關生死的緊急處置，必須優先執行。
Chills, flank pain, and hypotension are classic signs of an acute hemolytic transfusion reaction, which is a medical emergency. The nurse's priority action is to stop the transfusion immediately to prevent further harm, then maintain IV access with saline and notify the provider.