病人在輸血過程中出現畏寒、側腹痛及心跳過速。護理師應採取的第一步行動為何？
A client is receiving a blood transfusion and develops chills, flank pain, and tachycardia. What is the nurse's first action?
- ANotify the physician通知醫師
- BStop the transfusion immediately✓ 正解立即停止輸血
- CAdminister an antipyretic medication給予解熱劑
- DSlow the rate of infusion減慢輸注速率
輸血過程中出現畏寒、側腹痛及心跳過速，是急性溶血性輸血反應（acute hemolytic transfusion reaction）的典型徵兆，這通常是因為輸入了 ABO 不相容的血液，導致紅血球破裂，釋放游離血紅素，進而導致腎衰竭與休克。護理師的第一步行動必須是「立即停止輸血」，以切斷抗原輸入，接著使用生理食鹽水維持靜脈路徑通暢，防止發生循環衰竭。這是輸血安全中最關鍵的處置流程。
Chills, flank pain, and tachycardia during a transfusion are classic signs of an acute hemolytic transfusion reaction, which is typically caused by transfusion of ABO-incompatible blood, leading to red-cell destruction, release of free hemoglobin, and ensuing renal failure and shock. The nurse's first action must be to immediately stop the transfusion to halt further antigen exposure, followed by maintaining a patent IV line with normal saline to prevent circulatory collapse. This is the most critical step in the transfusion-safety protocol.