護理師正在監測接受輸血的病人。應觀察哪項溶血性輸血反應的徵兆？
A nurse is monitoring a client receiving a blood transfusion. Which sign of a hemolytic transfusion reaction should the nurse observe for?
- ALow back pain and hypotension✓ 正解下背部疼痛和低血壓
- BCrackles in the lungs and dyspnea肺部囉音和呼吸困難
- CFever and chills after 2 hours輸血後 2 小時發燒和畏寒
- DItching and hives搔癢和蕁麻疹
急性溶血性反應（AHTR）的典型特徵包含腰背部劇痛（由游離血紅素阻塞腎小管引起）、發燒、寒顫以及因循環衰竭導致的低血壓。B 是過敏反應；C 是循環負荷過重（TACO）；D 常見於非溶血性發熱反應。及早識別溶血反應可降低急性腎衰竭風險。
The classic features of an acute hemolytic transfusion reaction (AHTR) include severe low back pain (caused by free hemoglobin obstructing the renal tubules), fever, chills, and hypotension due to circulatory collapse. Option D reflects an allergic reaction; option B reflects transfusion-associated circulatory overload (TACO); option C commonly represents a febrile non-hemolytic transfusion reaction. Early recognition of a hemolytic reaction reduces the risk of acute renal failure.
美國輸血程序嚴格要求 15 分鐘床邊觀察；台灣程序類似，但在人力吃緊下常依賴家屬觀察或電子監測。