病人正在進行輸血，隨後出現側腹痛、發燒及深色尿液。護理師應採取的第一個行動為何？
A client is receiving a blood transfusion and develops flank pain, fever, and dark urine. What is the nurse's first action?
- ASlow the transfusion rate減慢輸血速率
- BFlush the IV line with normal saline以生理食鹽水沖洗靜脈通路
- CStop the transfusion immediately✓ 正解立即停止輸血
- DNotify the physician immediately立即通知醫師
病患出現側腹痛、發燒及血紅素尿，這是典型的急性溶血性輸血反應跡象。此反應極具危險性，隨時可能導致腎衰竭及瀰漫性血管內凝血（DIC）。首要護理動作絕對是停止輸血以截斷致病因子，並維持管路暢通以利後續急救用藥，接著才通知醫師。
The client's flank pain, fever, and hemoglobinuria are classic signs of an acute hemolytic transfusion reaction. This reaction is extremely dangerous and can quickly lead to renal failure and disseminated intravascular coagulation (DIC). The most important nursing action is to stop the transfusion immediately in order to remove the offending agent and to keep the IV line patent for the subsequent administration of emergency medications, after which the physician should be notified.
美國採取即刻行動權限較高，台灣醫療環境較強調需立即通報醫療團隊後再執行程序。