護理師照護一位正在接受輸血的病人，病人主訴畏寒、下背痛及發燒。護理師應採取哪些行動？（選所有適合的）
A nurse is caring for a client receiving a blood transfusion. The client begins to report chills, low back pain, and a fever. Which actions should the nurse take? (Select all that apply.)
- AStop the transfusion immediately✓ 正解立即停止輸血
- BDisconnect the blood tubing and start normal saline✓ 正解斷開輸血管路並開始輸注生理食鹽水
- CCall the physician✓ 正解通知醫師
- DSend the blood bag and tubing to the laboratory✓ 正解將血袋和管路送交實驗室
- EIncrease the infusion rate to flush the remaining blood加快輸注速度以沖洗剩餘血液
畏寒、下背痛與發燒是典型急性溶血反應。護理程序：停止輸血（A）、換掉整組輸血管並用 NS 維持靜脈暢通（B，注意需換掉整組管路以避免殘餘血液繼續進入）、通知醫師（C）、將血袋與管路送回血庫進行檢驗（D）。絕對不可增加流速，否則會惡化溶血反應。
Chills, low back pain, and fever are classic signs of an acute hemolytic transfusion reaction. Nursing procedure: stop the transfusion (A); disconnect the entire blood tubing set and maintain IV patency with normal saline (B, noting that the entire tubing set must be changed to prevent residual blood from continuing to infuse); notify the physician (C); and send the blood bag and tubing back to the blood bank for testing (D). Never increase the infusion rate, as doing so will worsen the hemolytic reaction.
台美輸血反應處理指引一致，皆強調立即更換管路與停止輸血。