護理師照護輸血病人，哪些徵象提示可能出現輸血反應？（選所有適合的）
A nurse is caring for a client who is receiving blood transfusion. Which findings indicate a transfusion reaction? (Select all that apply.)
- ATemperature elevation of 1.5°F✓ 正解體溫升高1.5°F
- BDevelopment of hives or pruritus✓ 正解出現蕁麻疹或搔癢
- CComplaints of flank pain✓ 正解主訴腰部疼痛
- DDecrease in blood pressure✓ 正解血壓下降
- ERespiratory wheezing✓ 正解呼吸喘鳴
輸血反應（Transfusion reaction）涵蓋多種免疫或非免疫性機轉，臨床上必須具備高度警覺。當病人出現任何異常徵象，護理師的首要行動是立即停止輸血，維持靜脈管路通暢（使用生理食鹽水），並通知醫師與血庫。本題各選項均為輸血反應的典型表現，涵蓋發熱性反應、過敏反應及急性溶血反應，皆屬於需要立即介入的緊急狀態。
Transfusion reactions encompass a variety of immune and non-immune mechanisms, and the nurse must remain highly vigilant. When any abnormal sign appears, the nurse's first action is to stop the transfusion immediately, maintain IV patency with normal saline, and notify the provider and blood bank. All of the options in this question represent typical manifestations of transfusion reactions—including febrile reactions, allergic reactions, and acute hemolytic reactions—each of which constitutes an emergency requiring immediate intervention.