護理師正在為病人輸血。15 分鐘後，病人主訴下背痛且體溫達到 38.4°C。護理師的第一步處置為何？
The nurse is monitoring a client receiving a blood transfusion. After 15 minutes, the client complains of lower back pain and has a temperature of 101.2°F (38.4°C). What should be the nurse's first action?
- ASlow the infusion rate and notify the physician.減慢輸注速率並通知醫師。
- BStop the transfusion and disconnect the tubing at the hub.✓ 正解停止輸血並在接頭處斷開管路。
- CRe-check the blood bag label and patient identifiers.重新檢查血袋標籤和病人識別資訊。
- DAdminister acetaminophen as ordered for the fever.依醫囑給予乙醯胺酚以治療發燒。
輸血開始後的首 15 分鐘是最容易發生急性溶血反應（Acute Hemolytic Reaction）的時間。下背痛（因腎小管被血紅蛋白阻塞）、發燒、發冷是溶血反應的典型徵兆。根據輸血護理準則，一旦懷疑有任何輸血反應，第一步永遠是「立即停止輸血」。接著必須斷開輸血管路，換上新的生理食鹽水管路以維持靜脈通路，而非只是調慢速度。這能防止更多不相容的血液進入體內。隨後才進行後續動作，如通知醫師、收集尿液檢體送檢、核對標籤等。這題考驗的是「安全優先」原則，在危及生命的反應中，移除致病源是首要任務。給予普拿疼（D）只是對症治療，會掩蓋病情；核對標籤（C）應在停藥後才做。
The first 15 minutes after starting a transfusion is when acute hemolytic reaction is most likely to occur. Low back pain (caused by hemoglobin obstructing renal tubules), fever, and chills are classic signs of a hemolytic reaction. According to transfusion-nursing standards, the first step whenever any transfusion reaction is suspected is to immediately stop the transfusion. The tubing must then be disconnected and replaced with new tubing and normal saline to maintain IV access, rather than merely slowing the rate. This prevents additional incompatible blood from entering the body. Subsequent actions follow, such as notifying the physician, collecting urine specimens for testing, and verifying labels. This question tests the principle of safety first: in a life-threatening reaction, removing the offending agent is the priority. Acetaminophen (D) only treats symptoms and may mask the clinical picture; verifying labels (C) should occur after stopping the transfusion.
美國 NCLEX 規範中，強調必須斷開管路至 Hub 並換上全新的 Y 型管路與 NS；台灣部分醫院實務中，護理師可能僅關閉輸血端而暫時保留原本的鹽水側管路，但在應考時必須選擇「完全更換新管路」以符合感染控制與防止殘血進入的標準。