— 降低風險 · MEDIUM · SATA —
護理師照護一位接受輸血的病人，哪些評估發現應立即通知醫師？（選所有適合的）
Which assessment findings should a nurse report immediately to the physician for a client receiving a blood transfusion? (Select all that apply.)
- ABack pain✓ 正解背痛
- BChills and fever✓ 正解寒顫與發燒
- CUrticaria✓ 正解蕁麻疹
- DHeart rate of 82 beats per minute每分鐘 82 次的心率
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
輸血反應（transfusion reaction）若未及時處理，可能導致嚴重的溶血性休克或器官衰竭。護理師必須監測輸血過程中的任何異常變化。背痛、寒顫、發燒、低血壓及蕁麻疹均為輸血反應的典型徵兆。一旦發現，必須立即停止輸血、維持靜脈管路通暢（以生理食鹽水取代輸血管路），並通知醫師，以防發生急性溶血反應。
Untreated transfusion reactions can lead to severe hemolytic shock or organ failure. The nurse must monitor for any abnormal change. Back pain, chills, fever, hypotension, and urticaria are all typical signs of a transfusion reaction. When detected, the nurse must immediately stop the transfusion, maintain IV access with normal saline through new tubing, and notify the provider to prevent acute hemolysis.