一位正在接受輸血的病人出現寒顫、下背痛與心搏過速。護理師優先採取的行動為何？
A nurse is caring for a client who is receiving a blood transfusion. The client begins to report chills, low back pain, and tachycardia. What is the nurse's priority action?
- AAdminister diphenhydramine給予苯海拉明
- BNotify the laboratory通知檢驗室
- CStop the transfusion immediately✓ 正解立即停止輸血
- DSlow the transfusion rate減慢輸血速率
輸血過程中出現寒顫、下背痛與心搏過速，是典型急性溶血性輸血反應（Acute hemolytic transfusion reaction）的徵兆，這是因 ABO 血型不合導致的嚴重免疫反應。護理師必須優先停止輸血（Stop the transfusion immediately），以防止更多抗原進入體內，隨後以維持通暢的生理食鹽水管路並通知醫師，這是護理安全的最優先級別。
Chills, low back pain, and tachycardia during transfusion are classic signs of an acute hemolytic transfusion reaction, a severe immune response caused by ABO incompatibility. The nurse must immediately stop the transfusion to prevent additional antigen from entering the body, then maintain a patent normal saline line and notify the provider. This is the highest priority in nursing safety.