病人出現輸血反應跡象。護理師的優先措施為何？
A client is experiencing signs of potential transfusion reaction. What is the nurse's priority action?
- ACall the physician通知醫師
- BObtain vital signs測量生命徵象
- CSlow the infusion rate減慢輸注速率
- DStop the transfusion immediately✓ 正解立即停止輸血
輸血反應（Transfusion reaction）屬於急性危急狀況。護理師的核心目標是移除抗原來源，防止反應持續惡化。一旦懷疑反應，必須採取「停止、維持、通報」原則：立即停止輸血，使用全新的生理食鹽水管路維持靜脈通路（KVO, Keep Vein Open）以利後續急救用藥，接著測量生命徵象並通知醫師。任何延遲（如減慢速度或先測量生命徵象）都會增加過敏原負荷，可能導致過敏性休克或溶血性反應。
A transfusion reaction is an acute, critical situation. The nurse's core goal is to remove the source of the antigen and prevent further worsening of the reaction. Once a reaction is suspected, the principle is to "stop, maintain, and notify": stop the transfusion immediately, maintain IV access (KVO, keep vein open) with new normal saline tubing for subsequent emergency medications, then take vital signs and notify the provider. Any delay (such as slowing the rate or taking vital signs first) increases the antigenic load and may lead to anaphylactic shock or a hemolytic reaction.
在美國，輸血反應處理流程高度標準化（Protocol-driven），護理師需立即停止輸血並以新的輸液管路給予生理食鹽水，這是 NCLEX 常考的核心安全措施。