一位 55 歲女性在大量創傷後正接受濃縮紅血球 (PRBCs) 的緊急輸血。輸血開始 10 分鐘後,病人出現胸悶、畏寒伴隨發抖,主訴下背部劇烈疼痛、呼吸困難與胸口壓迫感。生命徵象:血壓 85/50 mmHg、心跳 135 次/分、體溫 39.5°C。護理師辨識為急性溶血性輸血反應,應立即執行哪些護理介入?(多選題)

A 55-year-old female is receiving an emergency transfusion of packed red blood cells (PRBCs) following massive trauma. Ten minutes after the infusion begins, she develops chest tightness, chills with shivering, severe lower back pain, dyspnea, and a feeling of chest pressure. Vital signs: BP 85/50 mmHg, HR 135 bpm, temperature 39.5°C (103.1°F). The nurse recognizes this as an acute hemolytic transfusion reaction. Which immediate nursing interventions are required? (Select all that apply.)

• AStop the blood transfusion immediately and disconnect the blood tubing from the client's IV access.✓ 正解
  立即停止輸血，並將輸血管路從病人的靜脈通路斷開。
• BFlush the existing blood administration tubing with 50 mL of normal saline to clear residual blood from the line.
  用 50 mL 生理食鹽水沖洗現有的輸血管路，以清除管路內的殘餘血液。
• CMaintain IV access by replacing the tubing with new tubing primed with 0.9% normal saline.✓ 正解
  更換為已灌注 0.9% 生理食鹽水的新的管路，以維持靜脈通路。
• DSlow the transfusion to a keep-vein-open (KVO) rate to see if the back pain subsides.
  將輸血速率減慢至維持靜脈通路的速率（KVO），以觀察背痛是否緩解。
• ESend the discontinued blood bag, the tubing, and freshly drawn post-reaction blood and urine samples to the blood bank for analysis.✓ 正解
  將停止輸血的血液袋、管路以及反應後新採集的血液和尿液樣本送交血庫進行分析。