一位病人正接受輸血，輸注 15 分鐘後，病人主訴腰痛與寒顫。護理師的優先處置為何？
A nurse is caring for a client receiving a blood transfusion. Fifteen minutes into the infusion, the client reports low back pain and chills. What is the priority nursing action?
- ANotify the physician and the blood bank通知醫師和血庫
- BStop the infusion immediately✓ 正解立即停止輸注
- CSlow the infusion and monitor vital signs減慢輸注速度並監測生命徵象
- DAdminister acetaminophen for the pain and fever給予乙醯胺酚以緩解疼痛和發燒
腰痛和寒顫是溶血性輸血反應（Hemolytic Reaction）的典型徵兆。在懷疑任何輸血反應時，護理師的首要行動必須是立即停止輸注（Stop the infusion），並改用新的管路滴注生理食鹽水以維持靜脈通路。隨後的步驟包括通知醫師、核對標籤、採集檢體等，但絕不可先通知或先給藥而延誤停藥。
Low back pain and chills are classic signs of a hemolytic transfusion reaction. When any transfusion reaction is suspected, the nurse's first action must be to immediately stop the infusion and switch to a new line infusing normal saline to maintain IV access. Subsequent steps include notifying the physician, verifying labels, and collecting specimens, but the nurse must not notify or medicate first and delay stopping the transfusion.
美國 NCLEX 流程非常嚴謹：1. 停藥 2. 換管路滴 NS 3. 通知。台灣臨床有時會漏掉「換管路」而直接接 NS，須注意。