— 降低風險 · MEDIUM · SATA —
護理師觀察到接受輸血的病人出現下列何種情況需立即採取行動？（選所有適合的）
Which of the following findings in a client receiving a blood transfusion requires the nurse to act immediately? (Select all that apply.)
- ABack pain✓ 正解背痛
- BFlushed skin皮膚潮紅
- CFever✓ 正解發燒
- DWheezing✓ 正解喘鳴
- EStable blood pressure血壓穩定
— Explanation · 中文詳解 —
輸血反應的緊急徵象包含溶血性反應（背痛、發燒、低血壓）與過敏性反應（喘鳴、蕁麻疹）。背痛是嚴重急性溶血性輸血反應的特徵性症狀，必須立即停止輸血。發燒可能暗示發熱性非溶血性反應，喘鳴則顯示過敏反應，皆需採取嚴密的評估與處置措施。
Back pain, fever, and wheezing are critical signs of adverse transfusion reactions that require immediate nursing intervention. Back pain suggests an acute hemolytic reaction, fever indicates a febrile reaction, and wheezing signals potential anaphylaxis or airway compromise, all of which necessitate stopping the transfusion.
✦ 台美臨床差異
兩地輸血流程皆極為嚴謹，美國多依賴條碼驗證系統（Barcoding），台灣則常配合雙人核對簽名制度。