病人接受輸血 15 分鐘後出現畏寒、發燒及下背痛。護理師首要行動為何？
A client is receiving a blood transfusion and develops chills, fever, and low back pain 15 minutes after initiation. What is the nurse's priority action?
- ANotify the laboratory通知檢驗科
- BAdminister an antipyretic給予解熱劑
- CSlow the rate of infusion減慢輸注速度
- DStop the transfusion immediately✓ 正解立即停止輸血
輸血後 15 分鐘內出現發燒、畏寒與下背痛，是急性溶血反應（Acute hemolytic transfusion reaction）的典型徵兆。這是因 ABO 血型不相容導致的抗原-抗體反應，會造成紅血球大量破裂並導致腎衰竭，具有致死性。護理師的首要行動是立即停止輸血，確保不再有不相容血液進入體內，以保護病人安全。
Chills, fever, and low back pain occurring within 15 minutes of starting a transfusion are classic signs of an acute hemolytic transfusion reaction. This is caused by an antigen-antibody reaction due to ABO incompatibility, which leads to massive red blood cell destruction and can cause acute renal failure and death. The nurse's priority action is to stop the transfusion immediately so that no further incompatible blood enters the client's circulation.