病人輸血過程中出現寒顫、腰痛與低血壓，護理師應採取哪些措施？（選所有適合的）
Which of the following interventions should the nurse perform for a client receiving a blood transfusion who develops chills, flank pain, and hypotension? (Select all that apply.)
- AStop the transfusion immediately✓ 正解立即停止輸血
- BFlush the IV line with normal saline using a new tubing set✓ 正解使用新管路以生理食鹽水沖洗靜脈通路
- CAdminister acetaminophen to reduce the chills給予乙醯胺酚以減輕畏寒
- DNotify the healthcare provider✓ 正解通知醫療提供者
- ESend the blood bag and tubing to the laboratory✓ 正解將血袋與管路送交檢驗室
病人出現寒顫、腰痛及低血壓是典型的急性溶血反應徵兆。此為致命性併發症，須立刻停止輸血。接著使用新的輸液管路以生理食鹽水維持管路通暢，避免原本管內的殘血繼續注入。通知醫師是必須的，且必須保存血袋與管路以便實驗室進行交叉配對分析，確認溶血原因。服用乙醯胺酚對溶血反應無幫助。
The client's chills, flank pain, and hypotension are classic signs of an acute hemolytic transfusion reaction. This is a life-threatening complication, and the transfusion must be stopped immediately. New IV tubing with normal saline should then be used to keep the line patent and prevent additional residual blood from being infused. The provider must be notified, and the blood bag and tubing must be preserved and sent to the laboratory for crossmatch analysis to determine the cause of hemolysis. Administering acetaminophen does not address a hemolytic reaction.
兩地標準程序幾乎一致，皆強調輸血反應的立即處置流程（Stop, Maintain access, Notify, Return blood）。