— 降低風險 · HARD · MCQ —
護理師監測一位輸血病人的狀況。下列哪項症狀提示為溶血性輸血反應？
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following symptoms suggests a hemolytic transfusion reaction?
- AHeadache and mild fever頭痛和低燒
- BMild pruritus輕微搔癢
- CLower back pain and hypotension✓ 正解下背痛和低血壓
- DDelayed capillary refill毛細血管再充盈延遲
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）是因ABO血型不合導致的嚴重免疫反應。紅血球破裂釋放的血紅素引發血管內凝血與腎衰竭。臨床表現包含腰痛（腎臟血管收縮）、低血壓、發熱、心跳加速及呼吸困難。護理師必須依循安全原則，一旦懷疑反應發生，立即停止輸血，以生理食鹽水維持靜脈通路，監測生命徵象，並保留血袋及管路送回血庫檢驗。
Lower back pain and hypotension are classic signs of an acute hemolytic transfusion reaction, which occurs due to ABO incompatibility and subsequent red blood cell destruction. Other symptoms may include fever, chills, and dyspnea. Immediate cessation of the transfusion and maintenance of IV access with normal saline are critical nursing interventions upon suspicion of this reaction.