— 生理適應 · EASY · SATA —
護理師應針對輸血病患監測哪些徵象？（選所有適合的）
Which signs and symptoms should the nurse monitor for a client receiving blood transfusion? (Select all that apply.)
- ABack pain✓ 正解背痛
- BWheezing✓ 正解喘鳴
- CFever✓ 正解發燒
- DIncreased blood pressure血壓升高
- EPruritus✓ 正解搔癢
— Explanation · 中文詳解 —
輸血反應症狀廣泛，背痛是溶血反應的典型徵兆（腎臟受損）；喘鳴與搔癢（Pruritus）暗示過敏反應；發燒是發熱性非溶血性輸血反應或敗血症表現。高血壓通常不是輸血反應的典型徵象，反而需注意低血壓（休克）。
The nurse should monitor for back pain, wheezing, fever, and pruritus, as these indicate potential hemolytic, allergic, febrile, or bacterial reactions. Hypertension is not a typical sign of transfusion reactions; instead, hypotension is more commonly associated with severe adverse events like anaphylaxis or sepsis.
✦ 台美臨床差異
兩地輸血監測 SOP 相似，但美國更強調輸血後的 documentation 連結到電子病歷警示系統。