病人發生輸血反應，護理師的首要行動為何？
A client is experiencing a transfusion reaction. What is the first nursing action?
- AAdminister an antihistamine給予抗組織胺
- BCollect a blood sample收集血液樣本
- CNotify the physician通知醫師
- DStop the transfusion immediately✓ 正解立即停止輸血
輸血反應（Transfusion Reaction）的處置核心在於「阻斷抗原來源」。一旦懷疑病人發生輸血反應（如發燒、寒顫、背痛、低血壓、蕁麻疹等），護理師的第一優先行動（Priority Action）是立即關閉輸血管路（Stop the transfusion），並更換新的生理食鹽水（Normal Saline）管路以維持靜脈通道暢通。這是為了防止殘留在輸血器中的血液繼續進入病人體內，造成溶血或過敏反應惡化。
The core of managing a transfusion reaction is to interrupt the source of the antigen. As soon as a transfusion reaction is suspected (e.g., fever, chills, back pain, hypotension, urticaria), the nurse's priority action is to immediately stop the transfusion and replace the tubing with new normal saline to maintain venous access. This prevents any blood remaining in the tubing from continuing to enter the patient and worsening hemolysis or allergic reactions.
美國臨床要求發生輸血反應時，需將輸血袋及管路連同輸血紀錄單送回血庫（Blood Bank）進行調查，且必須在病人身上重新核對血袋標籤與病人辨識帶，這點與台灣做法一致，但美國護理師在執行時對於 chain of custody（監管鏈）的嚴謹度要求極高。