— 降低風險 · MEDIUM · SATA —
護理師監測一位接受輸血的病人。哪些表現顯示有輸血反應？（選所有適合的）
A nurse is monitoring a client who is receiving a blood transfusion. Which manifestations indicate a transfusion reaction? (Select all that apply.)
- AFever and chills✓ 正解發燒與畏寒
- BLow back pain✓ 正解下背痛
- CHypertension高血壓
- DFlushing of the face✓ 正解面部潮紅
- EShortness of breath✓ 正解呼吸困難
— Explanation · 中文詳解 —
急性輸血反應的典型徵兆包括發燒、畏寒（溶血或熱原反應）、腰背痛（溶血反應特徵）、面部潮紅（過敏反應）、呼吸困難（液體負荷過重或過敏）。高血壓通常不是輸血反應的直接徵兆，低血壓反而更常見於嚴重的過敏或急性溶血反應。
Classic signs of an acute transfusion reaction include fever and chills (hemolytic or febrile reactions), low back pain (a hallmark of hemolytic reactions), facial flushing (allergic reactions), and dyspnea (fluid overload or allergic reactions). Hypertension is not typically a direct sign of a transfusion reaction; hypotension is more commonly seen in severe allergic or acute hemolytic reactions.
✦ 台美臨床差異
美國醫院輸血需兩人雙重確認，台灣亦同，但美國護理師常有更明確的輸血後觀察期規範。