# 臨床情境 紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。 哪些措施屬於立即輸血反應應對？選擇所有適用者。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=603001&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

臨床情境
紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。

哪些措施屬於立即輸血反應應對？選擇所有適用者。

請選擇 4 個答案。

1

將部分使用的血袋送至輸血服務前，以生理食鹽水沖洗原血液管路。

2

通知處方醫師和輸血服務部門，並遵循反應協議。

3

暫停該血品、給予退燒藥，若寒顫與疼痛消退則重新輸注同一血品。

4

評估呼吸道、呼吸、循環、生命徵象和尿量。

5

根據授權，使用新的管路和生理食鹽水維持靜脈通路。

6

停止血液成分並斷開可疑管路。

## 解析

安全的應對措施是停止暴露、穩定個案、保留通路、啟動反應協議，並保留成分以供調查。可疑產品不得重新啟動或過早丟棄。

## 深入解析

快速解答
使用停止、評估、保留通路、通知和調查。

為什麼這是正確的
寒顫的暫時減輕並不能確定安全性。必須完成臨床反應以及文書、實驗室和成分調查。

簡單類比或心像
將每次輸注視為受控的臨床系統：驗證產品和通路、辨識變化的線索、停止可預防的暴露、穩定個案並確認反應。

記憶點
產品、通路、相容性、輸注線索、保護措施和重新評估。

NCLEX 決策規則
選擇能預防最直接輸注相關傷害的措施，同時保留血管通路和醫囑診斷證據。

為什麼其他選項是錯誤的
重新啟動可疑產品、繞過安全裝置、強行疏通阻塞的管路或延遲重新評估的選項，可能將可逆的警告轉變為嚴重的傷害。References
1CDC NHSN Hemovigilance Module Surveillance Protocol, January 2026Definitions and clinical patterns for acute hemolytic reaction, TACO, TRALI, and transfusion-transmitted infection
2CDC Clinical Guidance for Bacterial Contamination and Blood SafetyStop a suspected contaminated transfusion, preserve the unit, culture the patient, and investigate the residual component
3FDA-recognized Circular of Information for Blood and Blood ComponentsTransfusion reaction recognition, immediate discontinuation, product investigation, and supportive care

## 臨床情境

臨床情境
紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。

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