護理師照護一位正在輸血的病人。病人自述下背痛且畏寒。護理師的優先處置為何？
A nurse is caring for a client who is receiving a blood transfusion. The client complains of low back pain and chills. What is the nurse's priority action?
- ANotify the laboratory通知檢驗科
- BStop the transfusion immediately✓ 正解立即停止輸血
- CSlow the infusion rate減慢輸注速率
- DAdminister an antihistamine給予抗組織胺
輸血反應的評估遵循「安全第一」原則。下背痛、畏寒、發燒、呼吸困難及低血壓是典型的急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction, AHTR）徵兆，這是由 ABO 不相容引起的嚴重免疫反應，可能導致急性腎衰竭及瀰漫性血管內凝血（DIC）。護理師的首要行動必須是立即停止輸血，以切斷抗原-抗體反應的來源，接著使用生理食鹽水維持靜脈管路通暢，並監測生命徵象，確保病人血液動力學穩定。
Low back pain and chills during a blood transfusion are classic signs of an acute hemolytic transfusion reaction, often caused by ABO incompatibility. This is a medical emergency that can lead to acute kidney failure and disseminated intravascular coagulation. The nurse's priority action is to stop the transfusion immediately to halt the antigen-antibody reaction, then maintain IV access with normal saline and monitor vital signs.
在美國臨床實務中，對於輸血反應的處置流程（Protocol）極為嚴格，一旦發生任何輸血反應，護理師必須立即依據醫院Policy停止輸血、通知醫師並將血袋與管路送回血庫（Blood Bank）進行調查，這是維護病人安全與法律責任的重要環節。