— 基本照護與舒適 · HARD · MCQ —
病人輸血過程中出現哪些徵象，需要護理師立即介入？
Which assessment findings indicate an adverse reaction to a blood transfusion that requires immediate nurse intervention?
- ASlight itching without rash輕微搔癢但無皮疹
- BClient reports feeling warm at the infusion site病人報告輸注部位感覺溫暖
- CMild increase in heart rate of 5 bpm心率輕微增加 5 bpm
- DFever, chills, and lower back pain✓ 正解發燒、寒顫和下背痛
— Explanation · 中文詳解 —
輸血反應中，發燒、寒顫加上下背痛是溶血性反應（Hemolytic reaction）的典型表現。這是致命性的，需立即停止輸血並更換管路以生理食鹽水維持通路。其他選項如輕微心跳加快或微癢需觀察，但不如背痛警示般嚴重。
Fever, chills, and low back/flank pain during transfusion suggest acute hemolytic transfusion reaction—a life-threatening ABO incompatibility event that can progress to DIC, acute kidney injury, and shock. The transfusion must be stopped immediately, the line maintained with normal saline through new tubing, vital signs reassessed, and the blood bank/physician notified. A small rise in heart rate, mild itching without rash, or warmth at the site does not equate to the same urgency.
✦ 台美臨床差異
美台對輸血反應的緊急處理流程（停、報、沖）一致，均非常嚴謹。