護理師正在監測一名接受輸血的病患。15 分鐘後，病患主訴腰痛和發冷。優先的護理行動為何？
A nurse is monitoring a client receiving a blood transfusion. After 15 minutes, the client complains of lower back pain and chills. What is the priority nursing action?
- AStop the transfusion and disconnect the tubing at the hub✓ 正解停止輸血並在接頭處斷開管路
- BRe-check the blood unit's identification with another nurse與另一位護理師重新核對血袋標識
- CAdminister diphenhydramine as prescribed for allergic reactions依醫囑給予苯海拉明以治療過敏反應
- DSlow the infusion rate and notify the healthcare provider減慢輸注速度並通知醫療提供者
腰痛（Lower back pain）與發冷是「急性溶血性輸血反應」的典型徵兆。這通常是因血型不合引起，可能導致急性腎衰竭或 DIC。處理輸血反應的最高原則是：立即停止輸血！護理師必須關閉輸血管路，並在靠近病患的接頭處（Hub）斷開，改接生理食鹽水以維持靜脈通路通暢（但不可用原本沾有血液的管路沖洗）。減慢流速（D）是錯誤的，只要有反應就必須全停。事後重新核對（B）無法挽回已發生的溶血。此題考驗對致命性臨床反應的果斷處置。
Lower back pain and chills are classic signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency caused by incompatible blood types. The priority nursing action is to immediately stop the transfusion to prevent further administration of incompatible blood and minimize renal damage.
美國 NCLEX 規範中，停止輸血後必須將整套管路連同剩餘血液送回血庫檢驗；台灣臨床同樣嚴格執行此流程，且護理師在輸血前 15 分鐘必須全程在場監測生命徵象。