一位接受輸血的病人出現哪些臨床發現，應警覺可能有輸血反應？
Which assessment finding in a client receiving a blood transfusion should alert the nurse to a possible transfusion reaction?
- ABlood pressure increase from 120/80 to 125/82 mmHg血壓從 120/80 上升至 125/82 mmHg
- BTemperature increase of 0.5 degrees Celsius體溫上升 0.5 攝氏度
- CPulse rate decreasing from 80 to 75 bpm脈搏從 80 降至 75 bpm
- DComplaints of lower back pain✓ 正解主訴下背部疼痛
輸血反應中最嚴重的急性溶血反應，臨床症狀包括下背部劇烈疼痛、發燒、畏寒、低血壓及心跳過速。下背痛反映腎臟血流受阻。發燒 0.5 度在臨床上未達反應標準，心跳及血壓的輕微變動通常非輸血反應主要特徵，應優先處理具特異性的主訴。
Among transfusion reactions, the most serious is acute hemolytic reaction, whose clinical manifestations include severe lower back pain, fever, chills, hypotension, and tachycardia. The lower back pain reflects impaired renal blood flow. A temperature increase of 0.5 degrees Celsius is below the clinical threshold for a reaction, and small changes in heart rate and blood pressure are usually not characteristic features of a transfusion reaction; specific complaints should be prioritized.
台美皆嚴格執行雙人核對流程，輸血反應通報流程在兩地醫療品質指標中皆佔重要地位。