護理師監測接受輸血的病人。病人出現蕁麻疹、搔癢及臉潮紅。護理師的首要行動為何？
A nurse is monitoring a client receiving a blood transfusion. The client develops hives, itching, and flushing. What is the priority nursing action?
- ANotify the provider and continue monitoring通知醫師並繼續監測
- BAdminister the prescribed antihistamine給予處方之抗組織胺
- CStop the transfusion immediately and disconnect the tubing✓ 正解立即停止輸血並斷開管路
- DSlow the rate of the blood infusion減慢血液輸注速率
輸血反應（Transfusion reaction）的處理原則首重「安全（Safety）」與「終止來源」。蕁麻疹、搔癢及臉潮紅是過敏性輸血反應的典型徵兆。一旦發現，護理師必須立即停止輸血（Stop the transfusion），並斷開輸血管路，換上新的生理食鹽水管路以保持靜脈通路暢通，同時避免剩餘的血液繼續進入病人的循環系統。這是為了防止反應加劇，後續才進行評估與給藥。
The principles for managing a transfusion reaction prioritize safety and removing the source. Hives, itching, and flushing are classic signs of an allergic transfusion reaction. Upon detection, the nurse must immediately stop the transfusion, disconnect the blood tubing, and connect new tubing with normal saline to maintain IV access, while preventing the remaining blood from entering the client's circulation. This is intended to prevent the reaction from worsening before subsequent assessment and medication administration.
在美國臨床執業中，護理師在處理輸血反應時，必須嚴格遵守機構的 Policy，通常第一步就是停止輸血並更換管路，且需保留剩餘血袋送回血庫（Blood bank）進行分析，這一點與台灣臨床邏輯一致。