— 降低風險 · MEDIUM · SATA —
病人正在接受輸血，下列哪些評估發現需要立即回報？（選所有適合的）
Which assessment findings should a nurse report immediately for a client receiving a blood transfusion? (Select all that apply.)
- AFlank pain✓ 正解腰部疼痛
- BTemperature increase from 37.0°C to 37.2°C體溫從 37.0°C 上升至 37.2°C
- CDevelopment of urticaria✓ 正解出現蕁麻疹
- DDyspnea and wheezing✓ 正解呼吸困難與喘鳴
- EHeart rate change from 80 to 82 bpm心率從 80 變更為 82 bpm
— Explanation · 中文詳解 —
輸血反應需高度警覺。腰痛（Flank pain）是急性溶血反應的徵兆；蕁麻疹（Urticaria）是過敏反應的指標；呼吸困難與喘鳴（Dyspnea/wheezing）則暗示過敏性休克或循環負荷過重。輕微體溫升高或心率改變在臨床上多需持續監測，若無伴隨其他症狀則不一定需立即停止輸血。
A nurse must be highly vigilant for transfusion reactions. Flank pain is a sign of an acute hemolytic reaction; urticaria indicates an allergic reaction; and dyspnea with wheezing suggests anaphylaxis or circulatory overload. A minor temperature rise or a small change in heart rate generally requires continued monitoring, and unless accompanied by other symptoms, does not necessarily require immediate cessation of the transfusion.
✦ 台美臨床差異
台灣輸血護理特別要求輸血後 15 分鐘密切監測，美式護理則更強調對輸血反應定義的精準化判讀。