— 生理適應 · MEDIUM · MCQ —
護理師監測正在進行輸血的病人。哪項發現暗示可能有輸血反應？
A nurse is monitoring a client receiving a blood transfusion. Which finding indicates a potential transfusion reaction?
- AMild increase in blood pressure血壓輕微上升
- BBack pain and flank pain✓ 正解背痛和側腹痛
- CIncreased urine output尿量增加
- DStable vital signs生命徵象穩定
— Explanation · 中文詳解 —
輸血反應如急性溶血反應（Acute Hemolytic Reaction）的典型症狀包括背痛、腰側痛（腎臟受損跡象）、寒顫、高燒及心跳過快。背痛是因溶血產物阻塞腎小管所致，這是緊急狀況，需立即停止輸血並更換管路以生理食鹽水維持靜脈路徑。
Classic signs of an acute hemolytic transfusion reaction include back and flank pain (renal injury sign), chills, high fever, and tachycardia. Back pain reflects hemolytic products obstructing renal tubules—an emergency. The nurse must immediately stop the transfusion and maintain IV access with normal saline.
✦ 台美臨床差異
美國護理師對輸血反應的警覺教育極嚴，包含所有輸血反應的辨識細節，台灣在此領域也非常嚴謹，流程相似。