下列哪些評估結果顯示病人可能出現輸血後的全身性反應？（選所有適合的）
Which assessment findings indicate a potential systemic reaction to blood transfusion? (Select all that apply.)
- AChills and fever✓ 正解畏寒與發燒
- BBack or flank pain✓ 正解背部或脅腹疼痛
- CDyspnea and wheezing✓ 正解呼吸困難與哮鳴
- DIncreased urinary output尿量增加
- EHypotension and tachycardia✓ 正解低血壓與心搏過速
輸血反應涉及免疫系統對外來抗原的反應，嚴重者可能導致休克或器官衰竭。全身性反應的臨床症狀通常包括發熱、寒顫（發熱性非溶血性反應）、腰背痛（急性溶血性反應）、呼吸道症狀（過敏或輸血相關急性肺損傷 TRALI）及心血管不穩定（低血壓與心搏過速）。護理師在輸血過程中必須嚴密監測生命徵象，若發現上述症狀，應立即停止輸血，維持靜脈管路通暢（使用生理食鹽水），並通知醫師。
Transfusion reactions involve the immune system's response to foreign antigens and may, in severe cases, result in shock or organ failure. Clinical features of a systemic reaction typically include fever and chills (febrile non-hemolytic reaction), back or flank pain (acute hemolytic reaction), respiratory symptoms (allergic reaction or transfusion-related acute lung injury, TRALI), and cardiovascular instability (hypotension and tachycardia). During transfusion, the nurse must closely monitor vital signs; if any of these symptoms develop, the transfusion should be stopped immediately, IV access maintained patent (with normal saline), and the physician notified.
在美國臨床實務中，若懷疑輸血反應，必須『立即』停止輸血並以生理食鹽水（Normal Saline）沖管，這與台灣標準做法一致。關鍵差異在於美國護理師須嚴格遵循醫院輸血反應應對流程（Transfusion Reaction Protocol），包括立即將血袋與管路送回檢驗室進行複檢。