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一位個案在紅血球輸血開始後不久出現急性溶血反應的徵象。完成立即的護理處置。

Drop-down Cloze

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The nurse should immediately ::선택::slow the transfusion and observegive an antipyretic before changing the infusionflush the blood tubing into the clientstop the transfusion and remain with the client, then ::선택::remove all venous accessmaintain access with compatible normal saline through new tubing and notify urgent helprestart the same unit after blood pressure improvesdiscard the blood bag immediately. The investigation includes ::선택::documenting symptoms without notifying the blood banksending only a routine urine culturerechecking identifiers and sending the unit, tubing, and required specimens per protocolwaiting until the next day to compare records, while ongoing care requires ::선택::monitoring hemodynamics, urine output, renal function, hemolysis, and coagulationencouraging unassisted ambulationrestricting all fluid regardless of perfusionrestarting transfusion when chills stop.

護理師應立即 ::선택::減慢輸血速度並觀察在更換輸液前先給退燒藥將輸血管內血液沖入個案體內停止輸血並留在個案身邊，然後 ::선택::移除所有靜脈通路以相容的生理食鹽水經由新的輸液管維持通路，並通知緊急支援血壓改善後重新輸注同一袋血立即丟棄血袋。調查包括 ::선택::記錄症狀但不通知血庫僅送常規尿液培養重新核對辨識資料，並依規範將血袋、輸液管及所需檢體送檢等到隔天再比對紀錄，而持續照護需要 ::선택::監測血流動力學、尿量、腎功能、溶血及凝血功能鼓勵無人協助下走動不論灌流狀況一律限制所有液體寒顫停止後重新開始輸血。

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