護理師照護接受輸血的病人時，病人出現寒顫、腰痛及心搏過速。請問護理師首要採取的措施為何？
A nurse is caring for a client receiving a blood transfusion. The client develops chills, flank pain, and tachycardia. Which action is the priority?
- ADisconnect the blood tubing and initiate normal saline✓ 正解斷開輸血管路並開始輸注生理食鹽水
- BSlow the rate of the transfusion減慢輸血速率
- CNotify the laboratory of a possible error通知實驗室可能有誤
- DAdminister an antipyretic給予退燒藥
出現寒顫、腰痛及心搏過速為急性溶血性輸血反應的典型徵象。首要任務是立即停止輸血並以生理食鹽水維持管路通暢，避免持續輸注剩餘血液導致溶血加劇，並需保留輸血袋及管路送檢。降溫劑或減慢速度會延誤對溶血反應的處置，增加腎衰竭風險。
Chills, flank pain, and tachycardia are classic signs of an acute hemolytic transfusion reaction. The priority is to immediately stop the transfusion and maintain IV patency with normal saline to prevent further infusion of the remaining blood from worsening hemolysis; the blood bag and tubing must be saved for laboratory analysis. Administering antipyretics or merely slowing the rate would delay management of the hemolytic reaction and increase the risk of renal failure.
台美皆嚴格執行輸血反應處理流程，強調第一時間更換輸液管路，以排除血液殘留。