— 降低風險 · HARD · SATA —
護理師正在為病人進行輸血。應監測哪些急性溶血性輸血反應的徵象？（選所有適合的）
A nurse is caring for a client who is receiving a blood transfusion. Which signs of an acute hemolytic transfusion reaction should the nurse monitor for? (Select all that apply.)
- ALow back pain✓ 正解下背部疼痛
- BFever and chills✓ 正解發燒和畏寒
- CHypotension✓ 正解低血壓
- DBradycardia心動過緩
- EHemoglobinuria✓ 正解血紅素尿
— Explanation · 中文詳解 —
急性溶血性反應是致命的，因 ABO 血型不合導致紅血球破裂，釋放物質導致血管內凝血與腎衰竭。典型症狀包括背痛（因腎小管阻塞）、發燒、寒顫、低血壓、血紅素尿及心跳過快。心跳過慢（Bradycardia）非典型溶血反應，通常是心跳過快。
Acute hemolytic transfusion reactions are life-threatening events caused by ABO incompatibility, leading to red blood cell destruction. Key signs to monitor include low back pain, fever, chills, hypotension, and hemoglobinuria. Tachycardia is expected as a compensatory mechanism, whereas bradycardia is not a typical sign of this reaction.
✦ 台美臨床差異
台美對輸血反應的處置程序高度一致（立即停止、維持管路、送檢），但美國醫院多由輸血醫學實驗室介入，台灣則多由值班醫師處理。