護理師監測輸血中的病人，病人出現寒顫、下背痛及心搏過速。護理師應優先採取何種行動？
A nurse is monitoring a client receiving a blood transfusion. The client develops chills, low back pain, and tachycardia. Which action should the nurse take first?
- AStop the blood transfusion✓ 正解停止輸血
- BNotify the laboratory通知檢驗室
- CAdminister an antihistamine給予抗組織胺
- DSlow the rate of infusion減慢輸注速率
輸血反應中，寒顫、下背痛與心搏過速是急性溶血性輸血反應的典型徵兆，這是由於血液不相容導致紅血球大量破裂，血紅素釋放至血液中，進而阻塞腎小管。此反應具備高死亡風險。護理師的第一動作必須是立刻停止輸血，並更換點滴管路，以生理食鹽水維持靜脈管路通暢，這能防止持續溶血，並確保後續急救用藥與輸液能迅速進入體內。
Among transfusion reactions, chills, low back pain, and tachycardia are typical signs of an acute hemolytic transfusion reaction, in which incompatible blood causes massive red blood cell destruction and the release of hemoglobin into the circulation, leading to obstruction of the renal tubules. This reaction carries a high risk of death. The nurse's first action must be to immediately stop the transfusion and replace the IV tubing, maintaining IV patency with normal saline; this prevents continued hemolysis and ensures that subsequent emergency medications and fluids can be administered rapidly.