病人在輸血過程中出現腰痛、發燒與畏寒。護理師應立即採取的優先行動為何？
A client is receiving a blood transfusion. The nurse notes the client develops flank pain, fever, and chills. Which is the nurse's immediate priority action?
- ASlow the infusion rate減慢輸注速率
- BDisconnect the blood bag and tubing✓ 正解斷開血袋和輸血管路
- CAdminister an antipyretic給予解熱劑
- DNotify the healthcare provider通知醫療提供者
當病人出現腰痛（Flank pain）、發燒與畏寒，這是典型的急性溶血性輸血反應（Acute hemolytic transfusion reaction），通常是由於 ABO 血型不合導致。護理師的優先行動（Priority action）必須是立即停止輸血，以切斷抗原-抗體反應的來源，保護病人的腎臟功能。
When the patient develops flank pain, fever, and chills, this is the classic presentation of an acute hemolytic transfusion reaction, usually due to ABO incompatibility. The nurse's priority action must be to stop the transfusion immediately to cut off the source of the antigen-antibody reaction and protect renal function.
美國臨床對於輸血反應的處置極為嚴格，強調『Stop, Disconnect, Infuse Normal Saline』的標準作業流程。台灣臨床有時仍習慣先關閉輸血開關，但美國 NCLEX 考試中，『斷開並更換管路』被視為確保不會誤輸剩餘血液的必要安全動作。