護理師照護一位接受輸血的病人。輸血 30 分鐘後病人出現發燒與寒顫。護理師應優先採取哪項行動？
A nurse is caring for a client receiving a blood transfusion. The client develops a fever and chills 30 minutes after initiation. Which action should the nurse take first?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BNotify the laboratory通知檢驗室
- CAdminister an antipyretic medication給予退燒藥物
- DSlow the rate of infusion減慢輸注速度
輸血反應（Transfusion reaction）的處理遵循「立即停止、維持管路、通報醫師」的臨床決策順序。當病人出現發燒與寒顫，這可能是急性溶血性反應、發燒性非溶血性輸血反應或敗血症。護理師的首要任務是切斷過敏原或致病原的持續輸入，以減輕併發症的嚴重程度。停止輸血後，應使用新的生理食鹽水維持靜脈通路，以備急救給藥。
The management of a transfusion reaction follows the clinical decision sequence of stop immediately, maintain IV access, and notify the physician. When a client develops fever and chills, this may indicate an acute hemolytic reaction, a febrile non-hemolytic transfusion reaction, or sepsis. The nurse's first priority is to interrupt the continued infusion of the offending agent to reduce the severity of complications. After stopping the transfusion, new normal saline should be hung to maintain venous access in preparation for emergency medications.
美國醫院對於輸血反應的標準作業程序（SOP）非常嚴格，通常要求立即停止輸血並更換全新的點滴管路（Tubing）以生理食鹽水維持，並將血袋與管路送回輸血中心進行檢驗。台灣臨床亦遵循此原則，但美國護理師在確認反應時，會更強調依據「血庫政策」立即啟動輸血反應檢驗流程。