病人正在接受輸血。15 分鐘後，病人主訴下背痛與畏寒。優先行動為何？

輸血反應是輸血過程中可能發生的嚴重併發症，護理師必須具備快速識別和處理的能力。病人輸血 15 分鐘後出現下背痛和畏寒，這些是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction, AHTR）的典型徵兆。AHTR 是由血型不相容引起的免疫反應，導致紅血球被破壞，釋放血紅素，可能引發腎衰竭、彌散性血管內凝血（DIC）甚至死亡，屬於醫療急症。 在這種危急情況下，護理師的優先行動是立即停止輸血，並將整套輸血管路從靜脈導管上移除，以防止剩餘血液進入病人體內。同時，應維持靜脈通路，以便後續輸注生理食鹽水和給予急救藥物。這是臨床上處理急性輸血反應最關鍵的第一步，遵循「停止有害物質」的原則，以保護病人生命安全。

Transfusion reactions are serious complications that may occur during blood transfusion, and the nurse must be able to recognize and manage them quickly. Low back pain and chills 15 minutes after the start of transfusion are classic signs of an acute hemolytic transfusion reaction (AHTR). AHTR is an immune reaction caused by ABO incompatibility that destroys red blood cells and releases hemoglobin, possibly causing renal failure, disseminated intravascular coagulation (DIC), or death. It is a medical emergency. In this critical situation, the nurse's priority is to stop the transfusion immediately and disconnect the entire transfusion tubing from the IV catheter to prevent any additional blood from entering the client. The IV access should be maintained for subsequent normal saline infusion and emergency medications. This is the most critical first step in managing an acute transfusion reaction, following the principle of removing the harmful agent to protect the client's safety.