一位接受輸血的病人出現發冷、腰痛及心跳過速。護理師應優先採取何種措施？
A nurse is caring for a client who is receiving a blood transfusion. The client develops chills, flank pain, and tachycardia. What is the priority action?
- ANotify the physician通知醫師
- BStop the transfusion immediately✓ 正解立即停止輸血
- CSlow the rate of infusion減慢輸注速度
- DAdminister an antihistamine給予抗組織胺
此個案出現發冷、腰痛及心跳過速，這是典型的急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction），通常是因為 ABO 血型不合引起的免疫反應。護理師必須立即採取行動以防止進一步的溶血與腎衰竭。臨床優先順序為：1. 停止輸血；2. 以生理食鹽水維持管路通暢（更換輸液套組）；3. 通知醫師與輸血中心；4. 監測生命徵象並保存檢體。
The priority action is to stop the transfusion immediately, as the symptoms indicate an acute hemolytic reaction likely caused by ABO incompatibility. After stopping the blood, the nurse should maintain IV access with normal saline, notify the physician and blood bank, and monitor vital signs to prevent further complications such as renal failure.
美國臨床護理中，輸血反應發生時，必須立即更換一條新的生理食鹽水輸液管路，以避免殘留的血袋內容物繼續進入體內。台灣部分醫院亦遵循此流程，但護理師應特別確認各機構 Policy 對於輸血反應時管路處理的具體規範。