— 降低風險 · MEDIUM · MCQ —
護理師監測一位正接受輸血的病人，下列哪項發現暗示發生溶血性輸血反應？
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings would indicate a hemolytic transfusion reaction?
- ALower back pain and hypotension✓ 正解下背部疼痛和低血壓
- BLow-grade fever and mild itching低燒和輕微搔癢
- CWheezing and facial flushing喘鳴和面部潮紅
- DBradycardia and peripheral edema心搏過緩和外周水腫
— Explanation · 中文詳解 —
溶血性輸血反應（Hemolytic transfusion reaction）發生於輸入不相容的血液後，抗原-抗體反應導致紅血球大量破裂。釋出的血紅素會導致腰背痛（腎臟微血管栓塞）、低血壓、發燒及寒顫。這是一種生命威脅性的反應，需立即停止輸血並以生理食鹽水維持靜脈管路，以防進一步溶血導致不可逆的急性腎衰竭。
Lower back pain and hypotension are hallmark signs of a hemolytic transfusion reaction, caused by antigen-antibody destruction of red blood cells. This life-threatening reaction requires immediate cessation of the transfusion to prevent acute renal failure and shock.