— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師為病人輸血，哪些跡象應警示有急性溶血反應？（選所有適合的）
A nurse is administering a blood transfusion to a client. Which signs should alert the nurse to an acute hemolytic reaction? (Select all that apply.)
- ABack pain✓ 正解背痛
- BFever and chills✓ 正解發燒和畏寒
- CHypotension✓ 正解低血壓
- DBradycardia心搏過緩
- EFlank pain✓ 正解脇肋部疼痛
— Explanation · 中文詳解 —
急性溶血反應是嚴重的輸血併發症，通常由 ABO 血型不合導致。典型症狀包括背痛、脇痛、發燒、畏寒、低血壓、心跳過快及血紅素尿。護理師需密切觀察病人在輸血初期是否有這些不適，一旦懷疑，須立即停止輸血並保持管路暢通。
Acute hemolytic reactions, often caused by ABO incompatibility, present with signs such as fever, chills, back or flank pain, and hypotension due to systemic vasodilation and kidney injury. Nurses must recognize these symptoms early during transfusion to prevent severe complications, noting that tachycardia rather than bradycardia is typically observed.
✦ 台美臨床差異
台美皆要求輸血開始 15 分鐘密切監測，但美國護理師常須親自評估病人感受，台灣亦同，且常有輸血核對單。