— 降低風險 · MEDIUM · MCQ —
護理師監測一位正接受輸血的病人，哪項發現顯示病人可能有輸血反應？
A nurse is monitoring a client who is receiving blood transfusion. Which finding indicates a potential transfusion reaction?
- APatient feels slightly anxious about the procedure病人對該程序略感焦慮
- BTemperature increase from 98.6°F to 99.2°F體溫從98.6°F升高至99.2°F
- CClient reports lower back pain✓ 正解客戶主訴下背部疼痛
- DMild increase in heart rate to 88 bpm心率輕微增加至88次/分
— Explanation · 中文詳解 —
輸血過程中出現下背痛（lower back pain）是急性溶血反應的典型徵兆。這是因抗原抗體結合導致紅血球破裂，釋放物質刺激腎臟與背部肌肉，必須立即停止輸血並採取緊急應變措施。其他選項多屬非特異性或正常範圍。
Lower back pain during a blood transfusion is a classic sign of an acute hemolytic reaction. This occurs because antigen-antibody binding causes red blood cells to lyse, releasing substances that irritate the kidneys and back muscles. The transfusion must be stopped immediately and emergency measures initiated. The other options are mostly nonspecific or within normal range.
✦ 台美臨床差異
兩地均將輸血安全視為護理核心，美國對於輸血反應的緊急護理流程（停止、維持靜脈通路、通知）非常嚴謹。