病人接受輸血時出現寒顫、發燒及下背痛。護理師的第一個行動為何？
A client is receiving a blood transfusion and develops chills, fever, and low back pain. What should be the nurse's first action?
- ASlow the rate of the transfusion減慢輸血速度
- BStop the transfusion immediately✓ 正解立即停止輸血
- CAdminister acetaminophen for the fever給予乙醯胺酚以退燒
- DNotify the healthcare provider通知醫療提供者
病人接受輸血時出現寒顫、發燒及下背痛，這些是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction, AHTR）的典型徵兆。AHTR 是最嚴重且可能致命的輸血反應，通常是由於 ABO 血型不相容的血液輸入所致，導致受血者的免疫系統攻擊捐血者的紅血球。其核心概念是立即停止輸血，以防止更多的不相容血液進入病患體內，從而減少進一步的器官損傷和死亡風險。護理師的臨床思路必須以病人安全為第一優先，立即採取行動中斷危害，然後再通知醫師並進行後續處理。
Chills, fever, and low back pain are classic signs of an acute hemolytic transfusion reaction, which is a medical emergency caused by ABO incompatibility. The nurse's first action must be to stop the transfusion immediately to prevent further infusion of incompatible blood and minimize organ damage. After stopping the transfusion, the nurse should notify the provider and monitor vital signs.
美國 NCLEX 標準流程為：停血、換生理食鹽水管路、測生命徵象、通報；台灣流程相似，但強調必須保留血袋送驗。