護理師評估一位正在接受輸血病人的反應。哪項發現暗示可能發生輸血反應？
A nurse is evaluating a client's response to blood transfusion. Which finding indicates a potential transfusion reaction?
- ASlowly rising heart rate心率緩慢上升
- BStable blood pressure血壓穩定
- CIncreased urine output尿量增加
- DDevelopment of chills and low back pain✓ 正解出現寒顫與下背痛
輸血反應的早期發現與處理是 NCLEX 的測試重點。溶血性反應（Hemolytic Reaction）通常由 ABO 血型不合引起，機轉為抗體攻擊輸入的紅血球，導致細胞溶解、釋放發炎介質與血紅素尿。寒顫、下背痛（源於腎小管阻塞與發炎）及心跳過速是典型徵兆。護理師必須熟悉此類症狀，一旦發現需立即採取行動，優先順序為停止輸血，而非評估其他生命徵象。
Early recognition and management of transfusion reactions is a major NCLEX testing focus. A hemolytic reaction is typically caused by ABO incompatibility; the mechanism involves antibodies attacking the transfused red blood cells, resulting in cell lysis, release of inflammatory mediators, and hemoglobinuria. Chills, low back pain (from renal tubular obstruction and inflammation), and tachycardia are classic signs. The nurse must be familiar with these symptoms; once recognized, immediate action is required, with the priority being to stop the transfusion rather than to assess other vital signs.
美國醫院針對輸血反應的標準作業程序（SOP）非常嚴格，通常要求護理師在輸血後 15 分鐘內全程觀察，且一旦發生反應，必須將輸血袋與管路送回血庫（Blood Bank）進行檢驗。