病人正在進行輸血，突然出現畏寒、下背痛及心跳過速。護理師應採取何種優先行動？
A nurse is caring for a client who is receiving blood transfusion and starts to develop chills, low back pain, and tachycardia. What is the nurse's priority action?
- AAdminister an antihistamine as ordered依醫囑給予抗組織胺
- BSlow the rate of infusion減慢輸注速率
- CStop the transfusion immediately✓ 正解立即停止輸血
- DCall the physician通知醫師
這些症狀（下背痛、畏寒、心跳過快）是典型的溶血性輸血反應特徵，極度危險且可能致命。一旦懷疑溶血反應，第一優先步驟絕對是立即停止輸血，並維持管路暢通使用生理食鹽水，接著通知醫師並監測生命徵象。其他選項均非首要且可能延誤搶救時機。
These symptoms (low back pain, chills, tachycardia) are classic for a hemolytic transfusion reaction—an extremely dangerous and potentially fatal event. When a hemolytic reaction is suspected, the first priority is to stop the transfusion immediately, maintain IV access with normal saline, then notify the provider and monitor vital signs. The other options are not priorities and could delay life-saving care.
美國護理師依 protocol 執行輸血監控非常嚴謹，一旦發生反應即立即反應。台灣臨床上護理師需確認醫囑並嚴密守候頭 15-30 分鐘，緊急處理流程一致。