一位血色素 6.5 g/dL 的68歲女性病患正在接受紅血球濃縮液輸注。輸注過了 15 分鐘後，她按壓呼叫鈴並說：「我的下背部突然痛得要命，而且覺得全身發冷，胸口有點緊。」她目前的生命徵象為血壓 85/55 mmHg，心跳 120 次/分，體溫 38.8°C。護理師必須採取的「第一」處置為何？
A 68-year-old female patient with a hemoglobin of 6.5 g/dL is receiving a transfusion of packed red blood cells. Fifteen minutes into the infusion, she rings the call bell, stating, "My lower back suddenly hurts so badly, I have the chills, and my chest feels tight." Her current vitals are BP 85/55 mmHg, HR 120 bpm, and Temp 38.8°C (101.8°F). What is the FIRST action the nurse must take?
- AStop the blood transfusion immediately and maintain IV access with normal saline using new tubing.✓ 正解立即停止輸血，並使用新的管路以生理食鹽水維持靜脈通路。
- BCall the provider and the blood bank simultaneously to report the suspected reaction.同時通知醫師和血庫，報告疑似的輸血反應。
- CDecrease the transfusion rate and recheck vital signs in 5 minutes.減慢輸注速率，並在 5 分鐘後重新測量生命徵象。
- DAdminister STAT intravenous diphenhydramine and acetaminophen.立即靜脈注射二苯海拉明和乙醯胺酚。
本題測驗輸血反應的緊急安全處置。病患出現的突發性急遽下背痛（flank pain）、發燒畏寒（chills）以及低血壓（從正常降至 85/55 mmHg），是致命的急性溶血性輸血反應（Acute Hemolytic Reaction）的標誌表現，多為 ABO 血型不相容所致。面對任何疑似輸血反應，護理標準的第一步永遠是「立即停止輸血（Stop the transfusion）」，以切斷破壞的來源。接著，必須換上「全新的點滴管路」滴注 0.9% 生理食鹽水以維持靜脈通道暢通（選項A正確）。選項C如果只減慢流速而未停止，會繼續注入致命的錯誤血液。選項D給予抗組織胺和退燒藥是針對過敏或單純發熱性反應的後續處理，非優先且無法阻止溶血。選項B聯絡醫師與血庫是必要的步驟，但必須在停止輸血並確保病患生理防線之後才進行。
This item tests the emergency safety management of a transfusion reaction. The patient's sudden severe flank pain, fever with chills, and hypotension (dropping from normal to 85/55 mmHg) are hallmark manifestations of a life-threatening acute hemolytic transfusion reaction, most often caused by ABO incompatibility. For any suspected transfusion reaction, the first nursing standard step is always to immediately stop the transfusion in order to cut off the source of harm. Next, brand-new IV tubing must be used to infuse 0.9% normal saline to maintain venous access (option A is correct). In option C, merely slowing the rate without stopping the transfusion continues to deliver the lethal incompatible blood. Option D, giving antihistamines and antipyretics, is a follow-up management for allergic or simple febrile reactions; it is neither the priority nor capable of halting hemolysis. Option B, notifying the provider and blood bank, is a necessary step but must follow stopping the transfusion and securing the patient's physiologic safety.
台美在輸血反應急救步驟完全相同。要求立刻停止並「使用新管路沖 NS」是國考極經典的安全考點，不論在美國或台灣，若使用舊的輸血管直接接鹽水沖洗，會將剩餘的致命血液推入人體而造成嚴重傷害。