護理師評估一位正在輸血的病人，發現出現蕁麻疹與搔癢。護理師應優先採取哪項措施？
A nurse is assessing a client receiving a blood transfusion. The client develops hives and pruritus. Which action should the nurse take first?
- ANotify the healthcare provider通知醫療提供者
- BStop the transfusion immediately✓ 正解立即停止輸血
- CAdminister an antihistamine as ordered依醫囑給予抗組織胺
- DObtain vital signs測量生命徵象
輸血反應發生時，確保病人的安全是首要目標。蕁麻疹與搔癢為過敏反應徵兆，一旦發現應立即停止輸血，並更換輸液套管以生理食鹽水維持管路通暢，避免血液製品繼續進入循環。隨後才進行評估、給藥與通報醫師，不可延誤停止輸血的時機。
When a transfusion reaction occurs, ensuring client safety is the primary goal. Urticaria and itching are signs of an allergic reaction, and the transfusion must be stopped immediately and the tubing changed, with normal saline used to maintain line patency to prevent additional blood product from entering the circulation. Subsequent assessment, medication administration, and physician notification follow, but stopping the transfusion must not be delayed.
美台臨床對於輸血反應的緊急處理流程一致，均強調『停、換、通知、送回血庫』的標準化程序。