護理師照護一位正輸血的病人，病人突然表示腰痛且發冷。護理師應採取的首要動作為何？
A nurse is caring for a client who is receiving blood transfusion. The client suddenly reports flank pain and chills. What is the nurse's first action?
- ANotify the provider通知醫師
- BStart a normal saline infusion開始輸注生理食鹽水
- CAssess the client's vital signs評估病人生命徵象
- DStop the transfusion✓ 正解停止輸血
輸血反應（Transfusion reaction）的處理原則遵循「停止、維持、通知」的優先順序。當病人出現腰痛（Flank pain）和發冷（Chills）時，這高度懷疑為急性溶血性輸血反應（Acute hemolytic transfusion reaction），主因是輸入了不相容的血液，導致紅血球被破壞。首要動作必須是立即停止輸血，以減少後續抗原抗體反應對器官的損害。
Management of a suspected transfusion reaction follows the priority: Stop, Maintain, Notify. Flank pain and chills suggest an acute hemolytic transfusion reaction from ABO incompatibility, causing RBC destruction. The first action must be to immediately stop the transfusion to prevent further antigen-antibody damage; then maintain IV access with normal saline, assess vital signs, and notify the provider.
美國醫院對輸血反應的 Protocol 極為嚴格，通常要求「Stop transfusion, disconnect tubing at the hub, and start new NS with new tubing」。台灣醫院亦遵循相似原則，但美國護理師在執行時需特別注意不可將舊管路內的血液推入體內。