護理師監測接受輸血的病人。病人突然出現腰痛、發冷與發燒。護理師的首要行動為何？
A nurse is monitoring a client receiving a blood transfusion. The client suddenly develops flank pain, chills, and fever. What is the nurse's priority action?
- ASlow the rate of infusion減慢輸注速率
- BAdminister an antipyretic給予退燒藥
- CNotify the laboratory通知檢驗室
- DStop the transfusion immediately✓ 正解立即停止輸血
輸血出現腰痛、發燒、發冷，是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型徵兆，通常是因為血型不合導致。這是輸血併發症中最危急的情況，可能導致急性腎衰竭與休克。首要行動必須是立即停止輸血，確保病人安全，接著維持靜脈通路（用生理食鹽水），並立即通知醫師與血庫，以進行緊急處置。
Flank pain, fever, and chills during a transfusion are typical signs of an acute hemolytic transfusion reaction, usually due to ABO incompatibility. This is the most critical transfusion complication and can lead to acute renal failure and shock. The priority action is to stop the transfusion immediately to ensure patient safety, maintain IV access with normal saline, and then notify the physician and blood bank to initiate emergency management.