護理師正在照顧接受輸血的病人，病人出現發冷與背痛，護理師應先採取哪些措施？（選所有適合的）
A nurse is managing the care of a client receiving a blood transfusion. The client develops chills and back pain. Which action should the nurse take first? (Select all that apply.)
- AStop the transfusion immediately✓ 正解立即停止輸血
- BAdminister an antipyretic as ordered依醫囑給予解熱劑
- CFlush the IV line with normal saline✓ 正解以生理食鹽水沖洗靜脈管路
- DNotify the healthcare provider✓ 正解通知醫療人員
- ESend the blood bag and tubing to the lab✓ 正解將血袋和管路送交檢驗室
出現發冷與背痛高度疑似急性溶血反應，這是輸血緊急狀況。首要動作是停止輸血（A）並以生理食鹽水維持靜脈通暢（C），不可使用原輸血管路。隨後立即通知醫師（D），並將剩餘血品與管路送回檢驗以確認原因（E）。給藥（B）非第一優先，需先排除反應源。
Chills and back pain during a transfusion suggest an acute hemolytic reaction, a life-threatening emergency requiring immediate action. The nurse must first stop the transfusion to prevent further harm and flush the line with normal saline using new tubing to maintain IV access. Subsequent priorities include notifying the healthcare provider and sending the blood bag and tubing to the lab for investigation.
美台對於輸血反應的標準處置 SOP 高度一致，皆強調輸血安全的三核對與緊急應變機制。