病人正在輸血，開始 15 分鐘後主訴腰痛與發冷。護理師的第一步行動應為何？
A client is receiving a blood transfusion and reports low back pain and chills within 15 minutes of the start. What should be the nurse's first action?
- ASlow the infusion rate and notify the physician減慢輸注速率並通知醫師
- BRe-check the blood bag label against the client's ID將血袋標籤與病人身份再次核對
- CStop the infusion and disconnect the tubing✓ 正解停止輸注並斷開管路
- DAdminister acetaminophen as ordered依醫囑給予乙醯胺酚
腰痛、發冷、發熱、低血壓與心跳過快是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型症狀，這通常是因為 ABO 血型不合導致的嚴重免疫反應。護理師的第一優先行動是「停止輸血」，並立即更換新的管路接上生理食鹽水，以維持靜脈通路（KVO），接著通知醫師並監測生命徵象，以搶救生命。
Low back pain, chills, fever, hypotension, and tachycardia are classic symptoms of an acute hemolytic transfusion reaction, usually caused by a severe immune response to ABO incompatibility. The nurse's first priority action is to stop the transfusion, then immediately replace the tubing and infuse normal saline through a new line to keep the vein open (KVO), and then notify the provider and monitor vital signs in order to save the client's life.
在美國臨床，輸血反應時除了立即停止輸血並更換管路，必須將整袋血液與管路送回檢驗科（Blood Bank）重新核對；台灣的做法相似，但需特別強調護理師在第一時間的「立即停止」與「維持管路暢通」的優先順序。