護理師照護輸血病人時，出現哪些徵象應立即回報醫師？（選所有適合的）
Which assessment findings should a nurse report immediately to the provider for a client receiving a blood transfusion? (Select all that apply.)
- AChills and febrile response✓ 正解畏寒與發熱反應
- BLower back pain✓ 正解下背痛
- CUrticaria and itching✓ 正解蕁麻疹與搔癢
- DBlood pressure rise of 5 mmHg血壓上升 5 mmHg
- EDyspnea and wheezing✓ 正解呼吸困難與喘鳴
輸血反應的警訊必須立即回報。溶血性反應（Hemolytic Reaction）典型徵象包括發燒、畏寒、後背疼痛（腎臟受損警訊）、低血壓；過敏性反應則表現為蕁麻疹、搔癢、呼吸困難、喘鳴音。這些徵兆代表病人正處於生命危險，護理師需立即停止輸血、維持靜脈通道並通知醫師。血壓輕微變動若無其他症狀，需觀察但非立即危急。
Warning signs of a transfusion reaction must be reported immediately. A hemolytic reaction typically presents with fever, chills, back pain (a sign of renal injury), and hypotension; an allergic reaction manifests as urticaria, itching, dyspnea, and wheezing. These findings indicate the client is in life-threatening danger, and the nurse must stop the transfusion immediately, maintain IV access, and notify the provider. A small change in blood pressure without other symptoms warrants observation but is not an immediate emergency.