— 降低風險 · HARD · SATA —
護理師評估輸血病人，哪些症狀顯示可能出現溶血性輸血反應？（複選）
A nurse is assessing a client receiving a blood transfusion. Which finding indicates a potential hemolytic transfusion reaction? (Select all that apply.)
- ALow back pain✓ 正解下背痛
- BChills and fever✓ 正解畏寒與發燒
- CHypotension✓ 正解低血壓
- DBradycardia心搏過緩
- EHematuria✓ 正解血尿
— Explanation · 中文詳解 —
溶血性輸血反應（Hemolytic transfusion reaction）發生於輸入不相容血液時，抗體破壞紅血球，釋出大量血紅素至血液中。這些血紅素沉積於腎小管導致血尿，同時引發全身性發炎，導致發燒、背痛（腎臟受損與血管收縮）、低血壓（血管擴張與休克）。護理師若發現這些症狀，應立即停止輸血並維持管路暢通，以防致命性併發症。
Signs of a hemolytic transfusion reaction include low back pain, chills, fever, hypotension, and hematuria due to red blood cell destruction and renal involvement. Bradycardia is not expected; tachycardia typically occurs as a compensatory mechanism for hypotension.