— 降低風險 · EASY · MCQ —
護理師監測正在輸注紅血球濃縮液的病人。輸血 15 分鐘後，病人主訴下背痛及寒顫。護理師應先採取哪項行動？
The nurse is monitoring a client receiving a unit of packed red blood cells. Fifteen minutes into the transfusion, the client reports lower back pain and chills. Which action should the nurse take first?
- AStop the transfusion✓ 正解停止輸血
- BCheck the client's vital signs測量個案的生命徵象
- CNotify the physician通知醫師
- DSlow the rate of the transfusion減慢輸血速率
— Explanation · 中文詳解 —
下背痛與寒顫是急性溶血反應（Acute Hemolytic Reaction）的典型特徵，極度危險。懷疑任何輸血反應時，第一步絕對是立即停止輸血並改掛生理食鹽水維持管路，然後才通知醫師及測量生命徵象。絕不可僅調慢流速。
Lower back pain and chills are classic signs of an acute hemolytic transfusion reaction, which is life-threatening. The nurse must immediately stop the transfusion to prevent further incompatible blood from entering the patient before notifying the provider or assessing vital signs.
✦ 台美臨床差異
美國 NCLEX 與台灣臨床輸血指引完全一致：停止輸血、更換全新 Y 型管輸注 NS、保留血袋送驗。