病人正在進行輸血，出現畏寒、下背痛與心跳過速。護理師應採取的第一步措施為何？
A client is receiving a blood transfusion and develops chills, low back pain, and tachycardia. What is the nurse's priority action?
- ADisconnect the blood tubing and infuse normal saline✓ 正解斷開輸血管路並輸注生理食鹽水
- BNotify the laboratory通知檢驗室
- CSlow the infusion rate減慢輸注速率
- DAdminister an antihistamine as ordered依醫囑給予抗組織胺
輸血反應中，急性溶血性反應（Acute hemolytic reaction）是最危險的，通常由 ABO 血型不合引起。症狀包括寒顫、下背痛、心跳過速、低血壓與血尿。護理師的第一步行動（Priority action）是立即停止輸血，並拔除輸血管路更換生理食鹽水，以維持靜脈管路通暢，並防止殘餘血液繼續輸入體內。
Chills, low back pain, and tachycardia during transfusion suggest acute hemolytic transfusion reaction (often ABO incompatibility). The priority is to STOP the transfusion immediately and disconnect the blood tubing, then maintain IV access with normal saline using new tubing (to avoid infusing residual blood from the old line), notify the physician and blood bank, and monitor vital signs. Antihistamines and slowed rates are not appropriate for hemolytic reactions; lab notification is required but follows cessation.
在美國，輸血反應處理流程稱為「Transfusion Reaction Protocol」，護理師需立即啟動並通知醫師，同時將剩餘血液與管路送回血庫進行檢驗。