護理師監測一位正在輸血的病人，病人出現寒顫、下背痛及心跳過速。護理師應優先採取哪項行動？
A nurse is monitoring a client who is receiving a blood transfusion. The client develops chills, lower back pain, and tachycardia. Which action should the nurse take first?
- ASlow the transfusion rate減慢輸血速度
- BStop the transfusion immediately✓ 正解立即停止輸血
- CObtain a urine specimen取得尿液檢體
- DNotify the healthcare provider通知醫療提供者
寒顫、下背痛及心跳過速是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型症狀，這是因輸錯血型導致紅血球遭到破壞，釋放出的血紅素會阻塞腎小管，可能導致急性腎衰竭甚至死亡。根據安全護理原則，若發現輸血反應，第一時間必須停止輸血（Stop the transfusion），並以生理食鹽水維持靜脈管路通暢，以防血液殘留持續反應。
Chills, lower back pain, and tachycardia are classic symptoms of an acute hemolytic transfusion reaction, in which an ABO incompatibility causes red blood cell destruction; the released hemoglobin obstructs renal tubules and can lead to acute kidney injury or death. According to safe nursing principles, when a transfusion reaction is identified, the first action is to stop the transfusion immediately and keep the IV line patent with normal saline to prevent the remaining blood from continuing the reaction.
台美臨床上皆強調「立即停止輸血」為首要。美國護理程序中，停止輸血後需將點滴管路與血袋一併送回血庫檢驗，此點在 NCLEX 考試中常被強調。