— 降低風險 · HARD · SATA —
護理師照護輸血病人，哪些症狀顯示病人發生溶血性輸血反應？（選所有適合的）
A nurse is caring for a client receiving a blood transfusion. Which signs indicate a hemolytic reaction? (Select all that apply.)
- ALow back pain✓ 正解背痛
- BFever and chills✓ 正解發燒與畏寒
- CHypotension✓ 正解低血壓
- DBradycardia心搏過緩
- EHemoglobinuria✓ 正解血紅素尿
— Explanation · 中文詳解 —
急性溶血反應是致命性的嚴重併發症，表現包括腰背痛（腎臟受損反應）、發燒畏寒、低血壓（休克）、血紅素尿（腎絲球堵塞）。D 錯誤，溶血反應通常引發心跳過速而非過慢。出現這些症狀應立刻停止輸血，並以生理食鹽水維持靜脈管路暢通。
Acute hemolytic transfusion reaction is a life-threatening complication and manifests with low back pain (renal injury), fever and chills, hypotension (shock), and hemoglobinuria (renal tubular obstruction). Option D is incorrect because hemolytic reactions typically cause tachycardia rather than bradycardia. When these symptoms occur, the transfusion must be stopped immediately and the IV line maintained with normal saline.
✦ 台美臨床差異
美台對輸血反應的處置流程高度一致，皆首重停止輸血與通報。