— 降低風險 · HARD · SATA —
護理師照護正在接受輸血的病人，下列哪些徵象顯示發生溶血性反應？（選所有適合的）
A nurse is caring for a client who is receiving a blood transfusion. Which signs indicate a hemolytic reaction? (Select all that apply.)
- ALow back pain✓ 正解腰部疼痛
- BFever and chills✓ 正解發燒與畏寒
- CHypotension✓ 正解低血壓
- DSudden increase in heart rate✓ 正解心跳突然加快
- EWheezing喘鳴
— Explanation · 中文詳解 —
溶血性輸血反應是危急狀況，起因於 ABO 血型不合，紅血球破裂導致發炎反應。典型症狀包括腰痛（腎臟小管受損）、發燒發冷、血壓下降及心跳加快。E（喘鳴）通常與過敏性反應或容量過荷（TACO）有關，非溶血性反應典型症狀。
Signs of a hemolytic transfusion reaction include low back pain due to renal tubular damage, fever and chills from systemic inflammation, hypotension from vasodilation, and tachycardia as a compensatory response to shock. Wheezing is not typical of hemolytic reactions but suggests an anaphylactic or allergic response.
✦ 台美臨床差異
輸血護理規範兩地極為相似，皆強調輸血前雙人核對及發生反應時立即停止輸血並更換管路。