護理師正在監測一位接受輸血的病人。輸血開始十分鐘後，病人主訴畏寒、腰痛和胸悶。護理師的首要行動為何？
A nurse is monitoring a client receiving a blood transfusion. Ten minutes after the start of the transfusion, the client reports chills, low back pain, and chest tightness. What is the nurse's first action?
- AAdminister diphenhydramine as ordered依醫囑給予苯海拉明
- BSlow the infusion rate and notify the physician減慢輸注速度並通知醫師
- CStop the transfusion immediately✓ 正解立即停止輸血
- DCheck the client's vital signs and re-verify the blood bag測量病人的生命徵象並重新核對血袋
這題是輸血反應的經典考題。畏寒、腰痛（腰背痛是溶血反應的特徵）和胸悶提示發生了急性溶血性輸血反應（Acute Hemolytic Reaction）。在任何懷疑輸血反應的情況下，護理師的第一動作永遠是「停止輸血」。只有停止輸血，才能防止更多不相容的紅血球進入病人循環造成進一步傷害。選項 B（減慢速度）是絕對錯誤的，必須全停；選項 A 是處理過敏反應的藥物，但在確認反應類型前且未停藥前不應先給藥；選項 D（檢查生命徵象）是停藥後的後續步驟。整個流程是：停藥 -> 維持生理食鹽水路徑 -> 評估 -> 通知醫師與血庫。
This is a classic transfusion-reaction question. Chills, back/flank pain (a hallmark of hemolytic reaction), and chest tightness suggest acute hemolytic transfusion reaction. Whenever a transfusion reaction is suspected, the nurse's first action is always to stop the transfusion. Only by stopping can additional incompatible red blood cells be prevented from entering the client's circulation and causing further harm. Option B (slowing the rate) is absolutely incorrect; the transfusion must be stopped completely. Option A is medication for an allergic reaction, but no medication should be given before the reaction type is confirmed and before the transfusion is stopped. Option D (checking vital signs) is a subsequent step after stopping. The overall sequence is: stop transfusion -> maintain a normal saline line -> assess -> notify the physician and blood bank.
美國 NCLEX 考試流程非常僵化：Stop transfusion -> Disconnect tubing at the hub -> Start Normal Saline with *new* tubing。台灣臨床有時會直接從原本的 Y 型管轉開 N/S，但在考試中必須強調『使用新管路』以避免管路中殘留的血液進入。