— 降低風險 · MEDIUM · MCQ —
病人正在進行輸血，突然出現畏寒、發燒及下背痛。護理師優先採取之措施為何？
A client is receiving a blood transfusion and begins to experience chills, fever, and low back pain. What is the nurse's priority action?
- AAdminister an antipyretic給予解熱劑
- BStop the transfusion immediately✓ 正解立即停止輸血
- CSlow the rate of transfusion減慢輸血速率
- DNotify the laboratory通知檢驗室
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）是輸血中最嚴重的併發症，通常因 ABO 血型不合引起。症狀包括畏寒、發燒、下背痛、心搏過速與低血壓。護理師的首要任務是立即停止輸血，並更換新的點滴管路，以生理食鹽水維持靜脈管路通暢，隨後依照醫院指引回報醫師與血庫。
Chills, fever, and low back pain are classic signs of an acute hemolytic transfusion reaction, which is a medical emergency caused by ABO incompatibility. The nurse’s priority action is to immediately stop the transfusion to prevent further infusion of incompatible blood. After stopping the transfusion, the nurse should maintain IV access with normal saline and notify the provider and blood bank.