— 降低風險 · MEDIUM · MCQ —
護理師監測接受輸血的病人。下列哪項發現暗示可能出現溶血反應？
A nurse is monitoring a client receiving a blood transfusion. Which finding indicates a potential hemolytic reaction?
- AHypertension高血壓
- BBradycardia心動過緩
- CWheezing喘鳴
- DLow back pain✓ 正解下背痛
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute hemolytic transfusion reaction）是由於 ABO 血型不合導致的嚴重免疫反應。其典型症狀包含發燒、寒顫、低血壓、胸痛以及特異性的下背部疼痛（腰痛）。下背痛是由於溶血產生的游離血紅素導致腎小管阻塞，引起腎臟反應。一旦出現此徵象，必須立即停止輸血。
Acute hemolytic transfusion reaction is a severe immune reaction caused by ABO blood type incompatibility. Typical symptoms include fever, chills, hypotension, chest pain, and the specific finding of low back pain (flank pain). Low back pain results from free hemoglobin released by hemolysis obstructing renal tubules, causing a renal response. Once this sign appears, the transfusion must be stopped immediately.