一位病人輸血時開始抱怨背痛與臉潮紅，護理師的首要行動為何？
A client is receiving blood transfusion and starts to complain of back pain and flushing. What is the nurse's priority?
- ACheck the client's blood pressure測量病人的血壓
- BStop the transfusion immediately✓ 正解立即停止輸血
- CSlow the transfusion rate減慢輸血速率
- DAdminister an antihistamine給予抗組織胺
輸血反應中的背痛、臉潮紅、發燒、寒顫及呼吸困難是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型徵象。這是由於輸入的血液與受血者血型不合，導致抗原抗體反應造成紅血球大量破裂（溶血）。此反應可能導致急性腎衰竭、瀰漫性血管內凝血（DIC）甚至休克。護理師的首要行動必須是『立即停止輸血』，這是保護病人安全的最重要步驟，隨後應以生理食鹽水維持管路通暢，並通知醫師與輸血科進行後續調查。
Back pain, flushing, fever, chills, or dyspnea during transfusion suggest acute hemolytic transfusion reaction caused by ABO incompatibility, which can rapidly progress to DIC, acute kidney injury, and shock. The first priority is to STOP the transfusion immediately to prevent additional incompatible blood from entering circulation; then maintain IV access with normal saline through new tubing, notify the physician and blood bank, and return the blood product per protocol. Slowing the rate, antihistamines, or simply checking BP are not adequate first actions.
台美臨床對於輸血反應的標準處置程序（Protocol）高度一致，皆遵循「停止輸血、維持管路、通知醫師、傳回血液與血袋」的標準作業流程。