輸血發生反應時，護理師應優先採取哪項行動？

核心概念：處理輸血反應（Blood Transfusion Reaction）的優先護理行動。 為何正確答案對： A. 任何懷疑的輸血反應，無論是溶血、過敏、發燒或細菌污染，首要且最緊急的行動是立即停止輸血（Stop the transfusion）。這能終止潛在的有害物質（如抗體、細菌毒素）進入病人體內，是保護病人生命安全的第一步。 為何其他選項錯： A. 通知實驗室（Notify the laboratory）是後續步驟，通常在停止輸血並進行初步處理後才進行，以協助追溯問題。 B. 檢查生命徵象（Check the client's vital signs）雖然很重要，但必須在停止輸血後立即進行，停止輸血是更優先的行動。 D. 開始新的靜脈輸液線（Start a new IV line）通常是為了在停止反應血袋後，繼續輸注生理食鹽水以維持靜脈通路，並沖淡體內殘留的有害物質。但這必須在停止輸血之後，且通常是使用生理食鹽水，並非立即執行。

Core concept: Priority nursing actions for managing a blood transfusion reaction. Why the correct answer is correct: A. For any suspected transfusion reaction, whether hemolytic, allergic, febrile, or due to bacterial contamination, the first and most urgent action is to stop the transfusion immediately. This halts further entry of potentially harmful substances (such as antibodies or bacterial toxins) into the client's body and is the first step in protecting the client's life. Why the other options are wrong: B. Notifying the laboratory is a subsequent step, usually performed after stopping the transfusion and initiating preliminary management, in order to facilitate investigation. C. Checking the client's vital signs is important, but must be performed immediately after stopping the transfusion; stopping the transfusion takes higher priority. D. Starting a new IV line is generally used to continue normal saline infusion after stopping the offending blood, to maintain venous access and dilute any harmful residue in the body. However, this must follow cessation of the transfusion, is typically done with normal saline, and is not the immediate first action.